Client Intake Form

Past Life Regression - Client Intake Form

By completing this form, I will have more time to focus on your regression. Please submit your form at least 48 hours prior to your appointment. Your form will be sent to our office when you click the “Submit” button at the end. Thanks!

Information to Assist with Your Past Life Regression

Fields with an * are required.

*Appointment Date:

*Appointment Type :

Contact Information

*First Name :

*Last Name :

*Email Address :
You will receive a copy of this form by email.

*Phone Number :

Details to Help Susanne with Your Hypnosis

Age you are today :

What year were you born?

Occupation (if retired, from what) :

Why have you decided that now is the time to make an appointment?

*Any specific fears or phobias? NoneWaterHeightsStairsElevatorsEnclosed SpacesDogsCatsTouch on shoulder or foreheadCrowdsDeathOther

If "other" checked above, please explain:

Have you had any previous experience with Hypnosis/Hypnotherapy?

If yes, what type and why?

How did you hear about Susanne?

Information Disclosure/Liability Waiver

Susanne Wilson, the Carefree Medium, does not practice medicine, nor does she prescribe drugs or any related treatment. Hypnotherapy is a unique and separate profession as are counseling and psychotherapy.

There are no guarantees expressed or implied about any of your hypnosis sessions with Susanne. Hypnotherapy is not intended to be a replacement for medical or mental health care. It is offered here as a non-medical, non-chemical, non-invasive alternative to promote well being and spiritual growth. There are no refunds available on sessions.

Note: Those under the care of a physician should not ignore their doctor’s advice for medical problems. Consult your physician before making changes.

Regarding Hypnotherapy

Under hypnosis, your subconscious mind will always be in control, which means that YOU are always in control. You cannot be made to do anything that you do not truly desire to do, or anything that violates your moral or religious convictions. You will not tell Susanne any “secrets” nor will Susanne ask. The success of this process depends on your participation and willingness to use the spiritual knowledge you may receive, and your willingness to make changes as applicable.

There are times when one session can be effective in achieving your goal. However, hypnosis is a tool and it may be unrealistic to expect answers to all the “big questions” or expect life changing results in just one session. Sometimes multiple sessions may be required to achieve the desired effect.

Susanne reserves the right to audio record hypnosis sessions for her records or your benefit. All client records/materials are kept in confidence. After your session, please take 5 or 10 minutes to relax in our reception room or relax wherever you are, if meeting by phone. This transitional period will be beneficial.

Please use this area to send Susanne any comments or questions you want or need answered before or during your appointment. Thank you!

Acceptance of Terms

Acceptance of Terms - By selecting this box I am digitally signing this document and confirming that all submitted information is true to the best of my knowledge. I also acknowledge that I have read and understand the Information Disclosure and Liability Release Waiver.