Client Intake Form

All information provided is private and confidential.

No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

(* Required)

    Full Name*
    Address*
    Postal Code*
    City*
    Country*
    Mobile number*
    Email*
    Sex

    Date of Birth

    Occupation

    Relationship status

    Children & ages

    Women Only: Are you pregnant?

    Emergency contact

    Emergency contact's phone

    Are you currently under the care of a physician?

    If yes write his phone number

    Please list any health issues or requirements you would like me to know about (include health restrictions, allergies, or other health concerns)

    Reasons for seeking Past Life Regression Therapy?

    Are you taking any medication?

    Do you take recreational drugs and if so, what?

    Do you exercise?

    How many hours of sleep?

    What disrupts your sleep? How often does that happen?

    What is your typical diet like?

    What strategy do you use when you are stressed/angry or your nervous system feels dysregulated?

    Have you ever been in/going into hospital for surgery, mental or emotional illness?

    Please list any injuries you have or had

    Please list any traumatic or major life-threatening events that occurred in your life and what happened

    Are you currently experiencing any of the following?
    Nervousness
    - Inability to relax
    - Sleeplessness
    - Depression
    - Nail- biting
    - Nightmares
    - Sexual dysfunction
    - Compulsive tendencies
    - Teeth grinding
    - Poor health
    - Alcohol abuse
    - Drug abuse
    - Cigarette smoking
    - Compulsive
    - Overeating
    - Self-mutilation
    - Serious eating disorder
    - Co-dependency
    - Inability to focus attention
    - Poor memory
    - Marital problems
    - Recent divorce
    - War trauma
    - Childhood trauma
    - Illness or death of a loved one
    - Lack of energy
    - Low self-esteem
    - ADD or ADHD
    - Abusive home situation
    - Abusive work situation
    - Lack of success

    Please list things that you would like to do better

    What are your three most important lifetime goals

    What makes you happy? What do you enjoy doing?

    What is your greatest fear?

    What would your child self say about your life today

    What is your greatest dream for yourself?

    What would you like to achieve from these sessions?

    Do you have any additional comments or questions?

    How did you find me? (check all the applicable)
    Search Engine (like Google)Friend/AcquaintanceSocial MediaReferred by Physician/Complementary Health PractitionerOther


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