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Age Regression Intake Form
Regression is a hypnosis teqchnique used to assess memories from an earlier stage of one's life in order to help heal current issues. 
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First & Last Name *
1. Have you experienced hypnosis, hypnotherapy, or spiritual healing sessions?  How many? For what purpose? What was the outcome? *
2. What issues do you want to focus on today? What issue is your priority? Does your issue have a significant effect or pain that requires a therapeutic resolution? How long has it been an issue, and how has it changed over time?   *
3. How does this priority issue effect you in daily life. Give a specific example. What activities or behavior do you want to no longer do as actions? What activities or behavior would you now like to do instead?    *
4.  What emotions or thoughts do you want to no longer experience?  What emotions or thoughts would you now like to experience instead? *
5. What past resources do you have? What success or learnings have you had with directly or indirectly related issues in the past? *
6.  What past blocks might you have? What limiting beliefs or residual emotions could you address and heal, that may have a past known or suspected cause.   *
7.  New Way; What new actions thoughts and feelings would be good in future? *
8. What future benefits could come from taking this New Way? What future issues could arise if you continue with the Old Way? *
9.  Summarize what would you like to tell your subconscous, or what you feel your wise subconscous could tell you. *
10.  Do you have any questions? *
A copy of your responses will be emailed to the address you provided.
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