HEALED EGO

SCHH® Client Intake Form

We appreciate you taking the time to review this information, complete the enclosed form and supply us with the items requested below. Please fill out this New Client Assessment form prior to your appointment at least 5 days in advance. If the form is received the day of our meeting, we may need to spend time reviewing it, which takes time away from your healing session. Your healing sessions will consist of a quick introduction before we start and a wrap-up afterwards.

Session Date

Profile

Full Name

Phone

City & State

Zip/Postal Code

Country

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Email

Age

How were you led to me?

Health Profile

What is your current health goal?

What do you hope to get out of this session?

Areas of Concern

In this section, list your main issues and rate them by severity on a scale of 1-10, with 10 being the most severe. *Please note that we will address as many issues as possible, but it’s often best to deal with fewer at a time. This is why booking multiple sessions is important.

Concern/Issue #1

Severity 1-10

Concern/Issue #2

Severity 1-10

Concern/Issue #3

Severity 1-10

Concern/Issue #4

Severity 1-10

What do you believe is/are the cause(s) of these issues?

What have you done thus far to help alleviate these issues?

Are you currently under the care of a physician? If so, what for?

What are your most pressing current physical and/or emotional health issues?

Have you had any past accidents or medical operations?

Do you have any specific spiritual practice?

Medical History

Please answer the following questions in confidence.

Do you have a diagnosed medical Illness?

Yes No

Do you have a diagnosed psychological problem?

Yes No

Have you had any traumatic experiences in your life?

Yes No

Do you have any phobias?

Yes No

Are you taking any medications??

Yes No

Do you have any hearing problems?

Yes No

Are you currently Pregnant?

Yes No

How many pregnancies have you had?

Anything else you think I should know?

Yes No

Emotional Checklist

Do you have a problem with any of the following?

Alcohol Allergies Anger Anxiety Appetite/Eating Confidence Depression Drugs Fear Grief Guilt Habits Insecurity Marriage/Relationships Obsessions/Compulsions Pain Panic Attacks Phobias PTSD Self-Esteem Sex Sleep Smoking Sports Performance Stress Studying Suicide Weight Work Worry

Any problems not listed or that you would like to expand on?

Questions for your Higher Self

Privacy

Does Demitra have your permission to share your anonymous information on her YouTube Channel?

Yes No

Does Demitra have permission to share your edited video on her YouTube Channel if you have watched it first & are happy with the content?

Yes No

I understand the success of an Online Past Life Regression Session is based on my willingness to relax & push my conscious mind to the side.

Yes No

I understand that it is my responsibility to provide myself with a safe and comfortable environment in order to undertake the online session.

Yes No

I understand that if the internet connection should go down during the session, all I have to do to come out of the Theta state is to gradually become more alert until I am fully conscious.

Yes No

I understand that if I select YES, I agree to share my information anonymously & Demitra will share my anonymized information on her YouTube Channel.

Yes No

I understand that if I select YES, I agree to share my edited video & Demitra will post the edited video on her YouTube Channel.

Yes No

I understand that if I select NO to sharing my anonymized information and NO to sharing my video that Demitra will NOT share ANY of my information.

Yes No

Signature

Today's Date

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HEALED EGO

SCHH®​ Client Intake Form

Profile

Health Profile

Areas of Concern

Medical History

Emotional Checklist

Questions for your Higher Self

Privacy

FOLLOW HEALED EGO

SCHH® Client Intake Form