Neutralize-It Intake Form Although I personally don't need all of this information, I hope to help you learn how to gain insights into any problem by asking these questions. Your negative emotions are trying to let you know that there is imbalance within your energy field. Acknowledging your emotions and trying to understand them will help neutralize them. In your session, I will access the past situation and energetically neutralize any charge that has created the imbalance. This Form cannot be submitted until the missing fields (labelled below in red) have been filled in Neutralize-It Session Questionnaire 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 Problem:*Please describe the situation you consider a ‘problem’ What is that?If you were to view the problem as an outsider, studying your own energy in the situation, what do you observe? Problem symptoms*Describe the symptoms of the problem. Even issues that are not health related have symptoms. A financial lack problem might have symptoms such as a negative balance in your bank account, for example. Negative Emotions*Describe any negative emotions you are experiences as a result of the problem itself: State of mind before problem/symptoms began Did you have similar feelings before the onset of the problem/symptoms? Inciting Incident Can you think of a time when you first felt like this? (This is important, but if you can’t think of it, I will access it in the NeutralizeIt session) Responsible PartyIs there someone you hold/held responsible for your feelings? Need from Responsible Party In order to heal or feel better, is there something you need from those you feel are responsible for your feelings? Incident Benefit * Was there a benefit that you can think of that came from the incident? How did it make you a better person? Karmic IncidentCan you think of a time or times when you caused someone else to feel this same way? (That would make this a karmic pattern, which can be cleared with repentance. Ho’oponopono directed at relevant individuals should do the trick) Desired OutcomeI recommend that when you state your desire, you let go of analyzing why you have the ‘problem’ or what you think you “should” want. State what you want in terms of the physical. You can gain quite a lot of insights when you recognize any resistance in stating what you actually want, physically, that is not what the problem is. It’s okay to state how you want to feel, but I recommend that in addition to stating your physical desire. Not defining what you actually want is part of the reason you have the problem, but in forcing yourself to do so, you may see why you resist it in the first place. Also, try not to mention the ‘problem’, as in not having the problem. Please enter the word that you see below.