Past Life Regression Client Intake Form

Past Life Regression Client Intake Form
Practitioner Name:

Stacey McFarland

Business Name

Luna Rose Wellbeing

Email

wellbeingwithstaceyvictoria@gmail.com

Phone Number

07745176001

Qualification(s):

*Trainee Past Life Regression Practitioner

* Holy Fire & Usui Reiki Practioner

*Angelic & Crystal therapy

*Meditation & Circle Meditation Facilitator
Client Information
Name*

PrefixFirst NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Contact Name*
Emergency Contact Number*
Have you ever been diagnosed or experienced any of the following?*

AnxietyDepressionBipolar DisorderPTSD or TraumaDissociative DisorderPsychosis or SchizophreniaNone of the aboveOther
Are you currently under the care of a GP, Psychiatrist, or mental health professional?*

YesNo
If Yes please briefly explain.*
Are you currently taking any prescribed medication for mental health or mood support?*

YesNo
If yes please list*
Have you ever experienced dissociation, blackouts or memory loss?*

YesNo
Do you have any physical health conditions I should be aware of? e.g Epilepsy, Heart condition, Seizures*

YesNo
If Yes please specify *
Session Intentions
What has drawn you to past life regression at this time?*
Are their any specific issues, patterns or questions you would like insight or healing around?*
Do you have any previous experience with past lives/past life regression?
Have you experienced any healing modalities before?
Confidentiality & Data Protection

Your information is confidential and stored securely in line with GDPR regulations. It will never be shared without your consent, unless legally required
Disclaimer & Scope of practice

Please read and confirm each point
I understand that past life regression is a guided meditative experience and is not a substitute for professional medical or psychiatric treatment.I confirm I have disclosed any relevant mental or physical health conditions honestly.I understand I am responsible for my own wellbeing throughout the session.I know that if I feel overwhelmed or wish to stop the session at any point, I can do so.I understand that while emotional or spiritual insight may arise, this session is for self development purposes only and does not offer diagnosis or cure.I agree to seek medical or psychological support if needed and understand that this session is a complementary therapy, not a replacement for professional healthcare.
Consent to participate

By signing below I confirm that I:
Have read and understood the information aboveGive full and informed consent to participate in this past life regression sessionUnderstand my rights and responsibilities as a client
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Past Life Regression Client Intake Form

Session Intentions

Confidentiality & Data Protection

Disclaimer & Scope of practice

Consent to participate