CLINICAL AND TRANSPERSONAL REGRESSION WORKSHOP
Please complete this form to help us understand your background, health, and intentions for the training. Upon receiving the intake form, our team will process your application and send the payment details via WhatsApp.
EVENT DETAILS
9 May 2026, Saturday, 10am to 5pm. Venue: High Street Centre, 1 North Bridge Road, #12-08
Personal Information
Full Name
*
First Name
Last Name
Preferred Name
Email Address
*
example@example.com
Contact Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
Background & Experience
Prior experience in any of the following
*
Hypnotherapy
Counselling / Psychotherapy
Coaching
Energy Work (e.g. Reiki)
Meditation / Breathwork
None
Have you previously experienced hypnosis or regression work?
*
Yes
No
Briefly describe your previous hypnosis or regression experience
Intention for Attending
What brings you to this training?
*
What do you hope to gain from this experience?
*
Health & Psychological Well-being
Are you currently receiving therapy or counselling?
*
Yes
No
If yes, please specify
Which of the following have you experienced or been diagnosed with?
*
Anxiety / Panic Disorder
Depression
Trauma / PTSD
Dissociative experiences
Psychosis / Schizophrenia
Personality Disorders
None
Which of the following are you currently experiencing?
*
High emotional distress
Recent trauma or major life crisis
Difficulty regulating emotions
None
Safety & Suitability Acknowledgement
Please read and acknowledge: I understand that this training involves guided hypnosis and deep emotional exploration/ I acknowledge that I am mentally and emotionally stable to participateI understand that this training is not a substitute for medical or psychiatric treatment / I will inform the facilitator of any discomfort or distress during the session
I agree to the above
Consent
I consent to participate in this training voluntarilyI understand that I may opt out of any exercise at any time/ I understand that results and experiences may vary / I agree to maintain confidentiality of other participants’ sharing
I give my informed consent to participate
Emergency Contact
Emergency Contact Name
*
Relationship
*
Contact Number
*
-
Area Code
Phone Number
Submit
Should be Empty: