Past Life Regression Intake Form

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About
Solutions
Services
What is Hypnosis
What is Coaching
Contact
Events

Past Life Regression Intake Form

You’ve taken the first step to ignite change! So that I can better support you and tailor my approach to your specific needs, please complete this form prior to our session. Be advised completion may take up to 45 minutes. Thank you!

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Name

First

Last

I would like to receive emails about upcoming events.

Mobile Phone

Date of Birth

MM/DD/YYY

Address

Emergency Contact

Name and phone

Gender

Pronouns

Sexual Identity/Sexual Orientation

Current Occupation

Job and Career Satisfaction

Selected Value: 0

On a scale of 1-10, how would you rate your overall satisfaction with your job/career? 1 not satisfied, 10 very satisfied.

Health History

List any current health conditions, psychiatric diagnoses, medications you take regularly, and if you are currently working with a doctor, therapist, psychiatrist, or any other practitioner.

Have you done any inner work before, such as therapy, coaching, hypnosis, or other holistic or spiritual practices? If so, what was your experience?

What inspired you to seek a past life regression (PLR)?

Do you believe in reincarnation or past lives? How does your answer influence your intention for this session?

Do you consider yourself spirtual, religious, or open to metaphysical ideas?

Describe the role religion, faith, or spirtuality has played in your life. Also mention if you believe in spirits/angels/higher power/afterlife.

Are there areas of life you'd like to gain insight into?

What do you hope to achieve or gain clarity on? E.g. Relationships, origin of fears, life purpose.

If there was one question you could ask about your life or soul journey, what would it be?

Feel free to list more than one.

Do you feel drawn to specific time periods, cultures, or places without knowing why?

Have you experienced moments of profound insight, synchronicity, or transformation in your life? Please share.

Are there specific patterns or challenges in your life you feel could be connected to past experiences or lives?

Are there recurring fears, emotions, or limiting beliefs that feel difficult to explain or resolve?

Do you experience any unexplainable physical symptoms, such as pain, tension, or discomfort?

Describe nature of symptoms, what makes them worse and what provides relief if any.

Do you have feelings or behaviors that are difficult to explain in the context of your lfie experience?

Are there moments in your life when you've felt particularly stuck or blocked? If so, please describe.

Do you have recurring dreams, visions, or deja vu experiences that feel significant?

Do you feel you've inherited unresolved emotional patterns or generation wounds? If so, in what way?

Who in your life might have experienced any of the issues, blocks, or patterns you have described so far?

Include anyone that has come before you (think extended family, distant relatives, even several generations back--either individuals or your ancestors as a collective community).

If you could upgrade an area of your life, what would that be?

What life goals do you have and what do you hope your future looks like?

Have fun with this and describe your hopes and dreams! Include bucket list items, how you hope to feel, think, and behave in the future.

Family of origin

Two parent household? Single parent household? Blended family? Child of divorce? Adopted? Donor conceived?

Family Relationships

Please list parents/step parents/guardians and siblings. For each, list name, if living/deceased, age. Describe the nature of each of these relationships in detail.

Relationships

Please list partner/spouse and ALL other significant past relationships. For each, list name, if living/deceased, their age, the nature of the relationship, and the nature in which it ended (if applicable). If not currently in a relationship, describe a significant relationship you've had in the past and the nature in which it ended (divorce with custody battle, amicable break-up, etc).

Children

Name, living/deceased, age, nature of relationships, and any co-parent(s) if applicable. If you do not have children, describe if parenthood or remaining childfree is part of your goals.

General Life Experiences (check all that apply)

Accident with or without injury
Fire/Natural disaster
Bullying
Miscarriage
Abortion
Abuse (physical/emotional/sexual)
Unwanted sexual contact
Divorce / Separation
Domestic Violence
Family history of alcohol/substance abuse
Family history of mental illness
Family history of phobias
Hopsitalization for psychiatric illness
Victim of crime
Witness of crime
Victim of discrimination
Rejection by family
Legal problems
Financial problems
Job loss

General Life Experiences Comments

If you marked any of the items above, please provide additional details and context.

Loss history: identify all significant deaths in your life

Name, relationship to you, your age at time of death, cause of death, and the nature of grief

What do you like to do for fun?

Hobbies, passions, activities, creative outlets, social outings...

Is there anything else about your personal, emotional, or spiritual journey you'd like Kat to know?

How did you learn about Your Life Depot and Kat Shinoda?

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Hypnotherapy and Health Coaching with Kat Shinoda
Board Certified Health Coach (NBC-HWC) and Board Certified Hypnotist offering effective methods for weight loss, smoking cessation, alcohol sobriety, and overcoming fears. Proudly serving Montgomery County and surrounding areas, including Collegeville, Skippack, Kimberton, Oaks, King of Prussia, Lansdale, Phoenixville, Pottstown, Reading, Royersford, Paoli, Coatesville, Trappe, Downingtown, Malvern, West Chester, Media, Ambler, Chalfont, Gilbertsville, and Philadelphia.