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Past Life Regression - CONFIDENTIAL CLIENT INTAKE FORM

So we can help you in the best way possible, please answer all questions fully. If you have any questions regarding this intake form please contact Tania Davies at Mindful Impact Wellness Hub™ on 0409 994 660 or Tania@taniadavies.com

First Name *

Last Name *

Email *

Phone *

Postal Address *

City *

State *

Postcode *

Occupation *

Clients date of birth (dd/mm/yyyy) *

Age *

Gender *

How did you hear about Tania Davies? *

Did someone refer you? If yes, please let us know their name so we can thank them.

What is your priority goal to address during this Past Life Regression or Soul Regression Session? (give as much detail as possible to assist the therapist in guiding you effectively) *

What is your doctor's name and the name of their Clinic? This information is required for only a medical emergency only

Clinic - phone number

List any current health matters, illness or conditions of concern: *

List any medications you are currently taking:

Please briefly share anything else that would be helpful to know about you, (i.e., recent life-changing events such as deaths, divorce in the family, relationship difficulties, bullying, health issues, past trauma, accidents, etc.): *

Please list any other matters occurring in your life that negatively influence you in any way? *

Do you have an open mind towards the concept of reincarnation? *

Is there anything else you would like us to note prior to your first session?

Payment for Past Life Regression sessions are required in full no less than 48 hours prior to your appointment. Do you understand and agree to this requirement? *

Please indicate the full cost in AUD (before gst) that you are agreeing to pay for this session. *

Terms & Conditions - Past Life Regression

FEES & PAYMENT: Payment is due in full no less that 48 hours prior to your appointment by EFT or credit card. CANCELLATION POLICY: Your time slot is reserved exclusively for you. Please arrive promptly to obtain your full session. A 24-hour cancellation notice is required, except in an emergency. If you must cancel or reschedule due to an emergency, please notify us as soon as possible. In the event that you do not arrive for your session and proper prior notice has not been made, you will be charged the entire fee for the session. Thank you for your consideration. PREPAID SESSIONS: The above Cancellation Policy also applies to any programs with prepaid sessions. Failure to keep your appointment or non-emergency short-notice cancellations will result in the forfeiture of a prepaid session. No refunds will be given for unused prepaid sessions. All prepaid sessions are non-transferrable and will expire after three months. CONFIDENTIALITY: We will not release any client information to anyone without a written authorisation from you, except as provided for by law. MINORS: Appointments for children under age 18 require written consent from the parent or guardian. For optimum results, it is recommended that parents/guardians are not always there to accompany children during their session. SAFETY: Sessions may be video recorded for client and practitioner safety. These recordings are kept confidential and are securely filed. MEDICAL HYPNOSIS: Hypnosis is effective in relieving some medical conditions (i.e., pain management, migraines, IBS, etc.) but will require a signed release from your doctor or appropriate health care professional to avoid masking symptoms before proper diagnosis and/or medical treatment has been obtained. Of course, non-medical issues (i.e., smoking, weight loss, confidence, etc.) will not need a form. I understand Hypnotherapy (including Past Life Regression and Soul Regression Therapy) is not a replacement for medical treatment, psychological or psychiatric services or counselling and I also understand that the Hypnotherapist does not treat, prescribe for or diagnose any condition. RELEASE STATEMENT: I give my full consent to receiving sessions by Tania Davies and Mindful Impact™ for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my sessions depends greatly on my own ability and desire to affect change in myself. I understand that the results of my session(s) depend greatly upon my own serious participation and that Tania Davies and Mindful Impact™ cannot offer any guarantee of the success of my treatment. I am aware, however, that Tania Davies and Mindful Impact™ will do everything in their power to ensure my success and I agreed to participate in each session to the best of my ability. I hereby release Tania Davies and Mindful Impact™ from any liability. I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen Past Life Regression/Soul Regression/Hypnosis at this time. I have been advised that I am free to terminate any or all sessions at any time. I have accurately provided background information as requested by Mindful Impact™. I understand that, during the session/s, the practitioner may touch me as part of the necessary techniques. The practitioner will always advise of the location of described touch and I hereby give my permission for such touch to take place when necessary.

BY SUBMITTING THIS FORM

BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ MY CLIENT RIGHTS AND TERMS AND CONDITIONS. I FULLY UNDERSTAND AND ACCEPT WHAT I HAVE READ, THEREBY AGREEING TO THESE TERMS.

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