Client Intake Form/First Session

Below is a sample client intake form for your first Past Life Therapy appointment. Your client intake interview is very important because 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 thinking of the answers to these questions and bring this completed form to your first session, though it is not required. The questions below and several others will be discussed during your consultation.

Client name:                                                           Phone:
Date:                                                                      Email:

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 and F.A.Q. 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 and/or mate”

    e)  “when you are alone”

4.)  Describe your childhood experience…

    a)  “as a total experience”

    b)  “with mother”

    c)  “with father”

    d)  “with relatives and 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 time of birth?

6.)  What was your parents’ life situation during your mother’s pregnancy?

    a)  List/describe any previous traumas, miscarriages, falls, abusive patterns as victim and/or victimizer, confusing incidents, death of family member, parental separation, etc.

    b)  Any known, suspected, or attempted abortions including siblings?   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 and when did they begin or tend to reoccur?  Any allergies, infections etc.?

8.)  Any surgeries/hospitalizations (pregnancies, tonsillectomy, appendectomy, circumcision, hysterectomy, etc.)?  Any abortions?

    a)  What are they and at what age?

    b)  Which was the most difficult for you?   How did you feel physically and emotionally prior to 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 confrontation?

    a)  Give details of any recent stressful event or confrontation that occurred and its outcome. 

    b)  Have you ever been in any kind of accident 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 own 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 either extremely dominant or extremely passive?

    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?    Do you have a strong sense of boundaries in general?    Do you recognize and honor other people’s boundaries?

    c)  Hospitalizations for emotional reasons?

    d)  Ever hypnotized for any reason?

    e)  Are you familiar with de-hypnosis (focused-state)?     (Explained at

    f)  Are you currently taking any psychiatric medications?  If so, which ones are you taking or have taken in the past?

    g)  Recreational drugs now and/or in the past?  Do you smoke or drink and if so when do you feel the urge to do so and how often?

    h)  Any blank spots in memory?

15.)  Any prior therapy?   Where and what kind?   Any past life memories?  “Flashes”?   “Readings”?   Do you follow any particular religion now and if so which one?    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, homosexual, 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 or position 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 is ______________________________________________________________”

19.)  List any physical injuries, traumatic events, or any other emotionally charged, past experiences as they come to you.  (Let your intuition be a guide during this exercise and just list as many of them as you can remember.)  During the therapy experience, any pertinent events you did not mention or are not conscious of from this life and/or your past lives will surface but for now just list what you think may be important to resolve or discuss.





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