Client Intake Interview Form: First Therapy Session
 
Below is a sample client intake form for your first Past Life Therapy appointment. Your client intake interview is an essential part of the therapy process. It will provide some of your history and goals, serving as a guideline for future Past Life Regression Therapy sessions. The initial therapy session is also an opportunity to address any concerns you may have about our Past Life Therapy De-Hypnosis process. You may want to begin answering these questions before your first session, though it is not required. These sample questions (and others) asked of you during your intake interview consultation can be booked separately or as part of your initial therapy package. 
 
Name:                                                        
Phone:
Email:
Date:                                                                     
  
 
1.) How did you learn of my services?  Do you understand what Past Life Therapy is and a general understanding of the Past Life Therapy process using the Netherton Method? (Please visit https://www.pastlifetherapycenter.com/index.html and the FAQ page as a resource.)
 
2.) Why do you think you are considering Past Life Therapy and at this point in your life? 
 
3.) On a practical day-to-day basis, how do you want your life experience to change?
 
   a) “when you first awake in the morning.”
 
   b) “when at your job.”
 
   c) “when reacting to a boss or authority figures.”
 
   d) “with your friends or mate.”
 
   e) “when you are alone.”
 
4.) Describe your childhood experience
 
   a) “as a total experience.”
 
   b) “with your mother.”
 
   c) “with your father.”
 
   d) “with relatives and your siblings.”
 
   e) “with peers and other adults.”
 
   f) Were there any diseases or traumas that you or a relative experienced during your childhood?
 
   g) How do you feel your life is today because of your childhood?
 
5.) Do you know anything about your birth?
 
   a) Hospital or at home?
 
   b) Doctor, midwife, or both?
 
   c) Normal (head first) delivery?  Breech (feet or buttocks first) or c-section birth?
 
   d) Drugs?  Forceps?
 
   e) Any known problems at the time of birth?
 
6.) What was your parents' overall life situation (finances, living situation, in-law relations, etc.)  during your birth mother’s pregnancy (prenatal period) with you?
 
   a) List and describe any previous traumas, miscarriages, or falls during your mother's pregnancy with you, or challenges during your pregnancy, if applicable. Were your parents married or divorced at the time of your pregnancy? Were there any deaths of family members during any pregnancies or shortly after birth?
 
   b) Any known, suspected, or attempted abortions? Any spontaneous miscarriages?
 
   c) If there was a deliberate abortion directed towards you or a sibling, how was it performed?
 
      i)  by mother alone?
 
      ii)  in a hospital?
 
      iii) In what month (0-9)?
 
      iv) Any family members present?
 
7.) Any past/current health or physical conditions? Any chronic issues? If yes, when did they begin or reoccur? Any allergies, infections, etc.?
 
8.) Any surgeries/hospitalizations (pregnancies, tonsillectomy, appendectomy, circumcision, hysterectomy, etc.)? Any abortions or medical injuries?
 
   a) What are they and at what age?
 
   b) Which was the most difficult for you? How did you feel physically and emotionally before and after surgery?
 
9.) Did any surgery, event, or traumas seem to change your life, and if so, how? 
 
10.) Overall how do you handle stressful situations or confrontations?
 
   a) Give details of any recent stressful event or confrontation that occurred and its outcome. 
 
   b) Have you been in any accidents, including car accidents, falls, etc.? Do you know if you were unconscious during any of these incidents?
 
11.) Is it difficult for you to start or finish a project? 
 
If so, why? (This will be revealed and resolved in a therapy session if you do not know the answer.)
 
12.) Any phobias/fears?  Any repeated nightmares or dreams now or in childhood?
 
13.) Are there patterns in your behavior that seem unexplainable or uncontrollable?
 
   a) Are there destructive patterns in your relationship with others?
 
   b) Do you have any compulsive behaviors (compulsive eating, cleaning, sex, workaholic, etc.)?
 
   c) Do you experience wide mood swings?
 
   d) Are you overly dominant or passive sometimes or often?
 
   e) Any compulsive spending habits or financial issues now or in the past?
 
14.) Any periods of depression?
 
   a) Overly excited (manic)?
 
   b) Any periods of difficulty keeping reality boundaries (not feeling connected to yourself or life in general at times)? 
 
 c) Do you have a strong sense of boundaries in general?  
 
d) Do you recognize and honor your friends, family, and others, rules or boundaries?
 
   c) Hospitalizations for emotional reasons?
 
   d) Ever hypnotized for any reason?
 
   e) Are you familiar with de-hypnosis (focused-state)?    (Explained at PastLifeTherapyCenter.com)
 
   f) Are you currently taking any psychiatric medications or other pharmaceutical prescriptions? If so, which ones are you taking or have taken regularly in the past?
 
   g) Recreational drugs now or in the past? Do you smoke or drink? If yes, when do you feel the urge, and how often?
 
   h) Any blank spots in your memory?
 
15.) Any prior therapy?
 
If yes, where and what kind?  
 
a) Any past life memories, flashes, or readings? 
 
b) Do you follow any particular religion now or in the past?  
 
Is this the religion you have been practicing since childhood?
 
 
16.) Any sexual problems, unusual fantasies, or issues with accepting your sexual identity (straight, bi-sexual/curious, homosexuality, gender confusion, etc.)?
 
 
17.) What is your current occupation, and are you content with your current career choice/ position? Any hobbies? Why do you think you are attracted to your current field of business/job, or professional role, and are there any other types of professions or activities that interest you?
 
 
18.) Complete this sentence for me as easily and quickly as you can:
 
a) My life would be everything I want it to be if only
 
_____________________________________________________
 
b) However, what is preventing this from happening (as far as I know on a conscious level) is ______________________________________________________________
 
 
19.) List any physical injuries, traumatic events, or other emotionally-charged, past experiences as they come to you. Let your intuition guide you during this exercise. List as many of them as you can remember. During your past life regression therapy using de-hypnosis sessions, any pertinent events not mentioned from childhood or early adulthood (or that you're not conscious of yet) will surface. For now, prioritize what you think is most important to resolve or discuss.
 
 
 
 

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