This Form cannot be submitted until the missing fields (labelled below in red) have been filled in Hypnotherapy Intake Form Please note that all fields followed by an asterisk must be filled in. First Name* Last Name* E-Mail Address* Street Address City* State/Prov* Zip/Postal Code Country*CountryUnited StatesCanada----------------AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribadiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoFederated States of MicronesiaMoldovaMonacoMongoliaMontserratMoroccoMontenegroMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaS. Georgia and S. Sandwich Isls.Saint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamUS Virgin IslandsWallis and Futuna IslandsWestern SaharaYemenYugoslavia (former)ZaireZambiaZimbabwe Home Phone Birth Date (MM/DD/YYYY)* Gender* Male Female How do you plan to attend this session?* Over the phone. I will call you at 949-295-6135 at given time Microsoft Teams Jitsi Meet Other Type of session Traditional Hypnotherapy Session Past-life and/or Inner-life Session Have you experienced a hypnosis, past-life or inter-life regression session before? If so, what was your experience? How easy is it for you to quiet your mind and thinking? What are your reasons for wanting this session? What are your session objectives? Here are some examples of questions that can be asked during your session. Check the ones you're interested in knowing and then use the space below the examples to list your own. Life Selection Sample questions: Why did I select this life? Why did I choose the family I chose? What advantages does being me give me? What did my higher-self want to achieve in this lifetime? Divine Team sample questions: How many others are in my soul family? Who from this life is in my soul family? Who do I tend to incarnate with often? How many guides do I have? What about angels? Questions about lessons: What are the core lessons I wanted to learn in this lifetime? What lessons must I master yet? What lessons have I successfully mastered? Trauma + karma questions: Do I still have trauma stored in any of my bodies? If so, where is it and can we heal and release it now? Where are resistant energies stored? Can we heal and release them now? What else must I be doing to heal and protect myself? What negative karma must I still clear? What positive karma have I incurred? Relationships/Soul Contract questions: What did my soul contract with ___ involve? Is it completed? Why did my children choose me? How can I best support them? What other knowledge on relationships should I have? What other questions do you have? Optional: Please provide a 2-word phrase that can help expediate the process if you're induced again. (Can also provide at the end of your session) Have you read and agree to the information provided about a Hypnotherapy session with me?* Yes No Legal stuff* I am at least 18 years of age I have read and accept the terms of this session. I understand that you will use my information to contact me or send me the information I requested. Please complete the challenge that you see below. <