Client Intake Form for Past Life Regression Hypnotherapy

Full Name

First NameLast Name

Address

Street Address

State / ProvincePostal / Zip CodeCountry

Current Age

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Have you been hypnotized before? If so, what was the result?

Please describe your reasons for wanting to experience past life regression? Eg. I want to undertsand another life that helps me better understand why I......... in this life?

What significant patterns in your life have shown up and you would like clarity about? Patterns that seem to show up in different ways in your life but you can't understand why? Eg. Abusive relationshis.

Please provide details of your immediate family members and their ages.

Are there any significant loved ones that have passed that you would invite to provide you messages? Names and relationship, and favorite memory

Have you ever had epilepsy, depression, medical conditions, or illnesses? Please describe.

Are you currently taking any medications? If yes, please list them.

Do you have any physical pain now? If you do, where and how severe is this?

Have you ever suffered injuries to the same parts of your body or areas more than once? If so list area and injury.

Have you experienced any trauma, fears, or phobias such as heights, flying, underwater, etc.? If comfortable, please provide details.

Have you seen a Psychologist/Psychiatrist/Therapist? Please provide details.

Do you have any problems with sleep, dreams, or nightmares?

Do you have any addictions (e.g., alcohol, drugs, smoking, gambling, etc.)? Please specify.

Habits or Behaviours

Where is your Favorite Place in Nature

How do you relax

Were you brought up in a religious family

Have you ever had any thoughts of or attempted suicide

Please list your 10 questions for your higher self during the session

PERMISSION OF ELECTRONIC RECORD

PERMISSION FOR CASE STUDY TO BE USED

MEDICAL RELEASE: I understand I am responsible for my own health and wellbeing before, during and after this session. I confirm that I have no medical condition which prevents me experiencing hypnosis or related activities, and I further understand that this session in no way supersedes any medical or other treatment I may be undergoing from a medical or health practitioner. I also understand and agree that any hypnosis session is purely voluntary on my part.

I give my consent to be hypnotised by Soul Solace Hypnotherapy and I understand it is possible that the Past Life Regression process might uncover unpleasant past memories. I understand that the fee of $400 for this session is non-negotiable and I agree to pay this fee regardless of time taken or whether I am able to achieve a Past Life Regression or not. I am of legal age and in consideration of my own acceptance as a participant in hypnosis, hypnotherapy, counselling sessions, regression sessions, energy therapies, I for myself, my heirs, executors, administrators and assignees do hereby release and discharge Soul Solace Hypnotherapy from all claims of liability, damages, demands, and actions whatsoever in any manner arising from or growing out of my participation. I also understand that any advice or counselling given, while within the parameters of current modern Hypnotherapeutic Practice, is accepted and/or acted upon entirely at my own risk. In addition, I understand that, while highly successful, proven, cutting edge techniques are utilized, that No guarantee of any kind whatsoever is implied, promised, or bestowed.

Signed Consent

Please sign below to provide your consent.

Client Intake Form for Past Life Regression Hypnotherapy

Questions for Your Higher Self

Legal Release Form