Consent Form

Consent Form

Please fill in all the questions. If your answer is No, or not applicable, type in No or N/A
Full Name

First NameLast Name
E-mail
Address

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Date of Appointment

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Your date of birth

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Martital Status
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Do you have any ongoing medical problems? If so please briefly list the symptoms.
How long have you had these symptoms?
Briefly list any treatment for this issue and if it is still current
Fears or Phobias, please list
Complusive Habits, please list
Do you suffer from Asthma or Allergies, if so please list:
Have you ever suffered from Depression? If so list relevant details
Have you suffered from Epilepsy in the last two years? If so list relevant details
Have you ever had treatment from a Psychologist, Psychiatrist, or therapist? If so list details
Have you been hypnotised before? If yes, what was the reason and was it successful?
How did you find me?
Current state of health? List details
Are you taking any drugs or medications? If so list details
List details of any relevant major operations
To help me assist you, please outline details that I should know about your current situation, your issues and/or your hopes for the session/s with me.
Doctor's Name

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Doctor's Practice Name and Suburb

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Consent to Hypnosis.
Research Consent
Research and Publication Consent - The information I am about to recall about my past lives or life between lives may be used for research and/or publication by Karen Joy and/or the Newton Institute for LBL Hypnotherapy. I assign to Karen Joy the right to use my words and anonymised identity for valuable consideration, the sufficiency of which is acknowledged here. This may include written publications or speaking engagements to enlighten others about their purpose on earth knowing my name and any personal identifying information is not used other than age, gender and general occupation. I understand that my confidentiality will be completely honoured.
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Do you agree to be on my mailing list to receive twice monthly information on past lives, the afterlife new books I've written, relevant news and updates?
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Consent Form

Research Consent