Application for Past Life Regression Therapy
Dear Applicant,

In order to maximize your safety, please answer the questions honestly and thoroughly.

This service is available only in-person in my Taipei office, and you must be 21 years old or older.

If you have any of the following conditions, please do not apply, in order to protect your well-being:
1. Any kind of psychotic disorders (such as but not limited to: schizophrenia, paranoid disorder, etc.)
2. Any kind of personality disorders
3. Bipolar disorder
4. Suicidal
5. Conduct disorder
6. Oppositional defiant disorder
7. Breathing dysfunctions
8. Extremely low stemina
9. Uncomfortable to lie on your back or sit for an extended period of time

This is NOT a complete list of precaution warning. Only your honest and thorough disclosure below can ensure the best assessment.

Thank you for your patience and understanding.

Best,
Lillian Chen
www.freeryou.com

Your full legal name *
How would you like me to address you? *
Such as, Mary, Mr. Young, Billy, etc.
您的出生年月日 *
請留意這是西元喔。
MM
/
DD
/
YYYY
您的性別 *
若選擇其他,請在之後的空間,或前面那題希望的稱呼,告訴我您希望我用什麼性別/中性/無性別稱謂稱呼您。
Your e-mail address *
This is how I will contact you, so please make sure it is correct.
Your phone number *
Your Line contact info
Your home address *
The complete address of where you currently live.
Your languages *
Start with your most preferred Lagrange for communication.
Name of emergency contact person *
Choose someone who can actually help you in an emergency, instead of someone far away.
The emergency contact person's cell phone number *
The emergency contact person's languages *
The emergency contact person's relationship to you *
Such as, my father, my friend, my coworker, etc.
What medical/physical conditions do you have? *
Including but not limited to: diagnoses, undiagnosed conditions, chronic issues, temporary and current issues, past and still affecting issues, etc.
What psychiatric diagnoses do you have or have you ever had? *
Please be thorough.
If you have any personality disorder, what is it? *
What additional information about your medical and mental health conditions should I know? *
List all the medications, supplements, OTC drugs, recreational/illegal substance that you use. *
I will not voluntarily report your illegal use of substance.
Your alcohol consumption: what kind, how much, how frequently? *
Such as, one glass of red wine every evening, binge drinking whisky twice a week, etc.
How much and how frequently do you smoke? *
Such as, 5/day, 1 every 2 months, etc.
Why do you want to receive past life regression therapy? *
Have you ever received hypnosis? *
If you have ever received hypnosis, what was the experience like?
Anything else you'd like to tell me?
Do you understand and accept that your experience and outcome of this service may be different from your expectation? *
Do you understand and accept the risks associated to this service, and you will seek professional help (such as medical treatments, psychiatric treatments, counseling/psychotherapy, etc.) in case of adverse reactions? *
Enter your full legal name here as your signature, meaning that you are the prospective client seeking this service, and that you have provided all information honestly and thoroughly. *
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