Past Life Regression Therapy
This questionnaire typically takes 10 to 20 mins to complete.

The more you can tell me about yourself, the more I can assist you.
There is no judgement from me, no matter what you tell me, but if you are uncomfortable in any way with any of the following questions you can skip them (even if required * simply type No, uncomfortable or can't)
Feel free to write as much as you need to

All information will be kept strictly confidential except when there is a legally obligation to report, such as a threat of injury to yourself or others.

Please complete and send the form at a minimum of 48 hours before your appointment, if one has been scheduled.
I'm looking forward to receiving your completed form, Kirsty

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Personal Status *
Name of Spouse / Partner
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Children; names and ages
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