Empowerment Session Intake Form
Be grateful to yourself!  You have set the intention to write a new chapter in your life!  This is the beginning of you aligning with your best self.  I'm looking forward to accompanying you on your journey but I need to know some history first.  We are creating a loving, protected and safe space together! All information here and in any of our sessions is completely confidential        Lots of Love - Jessica
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First / Last Name *
Pronouns
Birthdate
MM
/
DD
/
YYYY
Phone *
Email *
Address
Where did you find me?
Tell me about what you're looking for out of the session
Sun Sign
What do you do for work? Are you happy in your position?
Tell me about your passions
What are your greatest fears?
What are some of the negative beliefs that you tell yourself?
Have you ever had hypnosis or a past life regression?  How was the experience?
Please list the names of your parents and how your relationship is.  Please note if they are not with us anymore and when they transitioned.
Please list the names of your siblings and how your relationship is with them.  Please note if they are not with us anymore and when they transitioned.
Are you in Relationship or Have Been Married?  Please List Name 
Do you have children? If so please list names, ages and any health issues
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