SOUL CONNECTIONS
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SOUL CONNECTIONS
Home
About
Women's Campout
Body Work
Massage & Journeys
Drumming Journey
Testimonials
Connecting Worlds
Sister Circles
Sister Circles
Cacao & Lotus
5 Week Immersion
Bridal Packages
Connect
Client Form True Direction Transformation Package
Client Form
Please complete the form below
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email Address
*
Presenting problem/s (what is it you would like help with?)
*
For how long have you had this problem?
*
What have you already tried to do about it?
*
Do you ever feel any positive/negative emotions?
Do you have any fears or phobias?
*
Yes
No
Do you have any Compulsive habits?
*
Yes
No
Do you suffer from asthma or allergies?
*
Yes
No
Have you suffered from epilepsy in the last two years?
*
Yes
No
Have you ever suffered from depression?
*
Yes
No
Have you ever had treatment from a psychologist/psychiatrist/ therapist?
Yes
No
If yes, please provide details:
Have you been hypnotized before?
Yes
No
Are you currently taking any drugs/medication?
Yes
No
Have you had a major operation?
*
Yes
No
Details of any major operations:
Have you ever heard of an unconscious mind?
Yes
No
Why do you want to let go of the problem?
*
How quickly would you like to let go of the problem?
We may give you some tasks to do before we see you. You must do those tasks, or we cannot see you. Do you understand and is that ok?
*
Yes
No
By initialling this form you are signing an agreement that you have read and understand the terms, conditions and will follow the directions of the practitioner.
Please type your full name
Thank you!
