Quantum Consciousness, Past Life Regression &

Life Between Lives Spiritual Integration

Consent Form REF (________-_________-__________)

Intake - HypnosisSoul Journeys - Consent - 2019-04 - V1.1 Page 1 of 2

Name Birth Date Age

Address Suburb Post Code

Mobile Email Address

How Did You Find Out About Us

Occupation Current Medications

Enjoyable pastimes? Your skills and talents?

Emergency Contact Relationship Mobile

Do you suffer with any of the following conditions? If so please tick the appropriate ones.

Anxiety Eating Disorder Headaches Migraine Panic Attacks Others:

Depression Fatigue Indigestion Nightmares Pain

Diabetes Fears Insomnia Obsessions Phobias

Have you ever been diagnosed with Dissociative Identity Disorder (Multiple Personalities), Psychosis, Schizophrenia or Epilepsy? (Provide details if applicable)

Ever experienced hypnosis? Did you “go under”? How long ago?

What is your primary objective in undertaking this session?

What are your spiritual, religious beliefs systems? (To ensure the session is in harmony with your beliefs)

For “Life Between Lives Spiritual Integrations” sessions only. (please complete the table below):

Persons Name Relationship To YOU What is significant about the relationship?

Signed Date First Name Last Name

Thank you for completing this side, now complete the second side

Quantum Consciousness, Past Life Regression &

Life Between Lives Spiritual Integration

Consent Form REF (________-_________-__________)

Intake - HypnosisSoul Journeys - Consent - 2019-04 - V1.1 Page 2 of 2

Please acknowledge each box after reading and agreeing to each clause:

� Quantum Consciousness Personal Universe Journey | Past Live Regression | Life Between Lives

Spiritual Integration - In order to provide the best support possible to you, HypnosisSoul will need to collect and record personal information, manually and electronically, during each session. The information will be used to set goals and to monitor progress which may be relevant for future sessions. Paper information will be stored in a locked filing cabinet and electronic information under password protection software.

� Access - You may access the material in your file upon request in writing at any time.

� Confidentiality - All personal information gathered by the Quantum Consciousness, Past Lives and Life Between Lives

facilitator / practitioner during the provision of the services will remain confidential and secure except when: It is subpoenaed by a court, or failure to disclose the information would place you and another person at risk, or your prior approval has been obtained to: provide a written report to another professional or agency, e.g. a GP or a solicitor, or to discuss the material with another person, e.g. a partner, parent or employer. To ensure that you receive the best possible care, details of your case may be discussed with the practitioner’s supervisor in confidential terms. During these discussions your identity will not be revealed.

� Fees For Services Provided - Fees are payable at the start of each session by cash, EFTPOS, Visa or MasterCard,

indicate the service you wish to receive by ticking the appropriate box.

.

� Authority To Charge A Credit Card - Please notes if for some reason you need to cancel or postpone an

appointment, 24 hours notice would be appreciated, failure to do so may incur a cancellation fee of $160. Accordingly, I hereby authorise the charging of consultation fees directly to my nominated credit card as detailed below:

(tick your card type)

Name On The Card Signed Date

Card Number Expiry Date CSV – last 3 Digits on Reverse

� HypnosisSoul and Andrew Reay abide by the charters of the:

The Australian Association of Clinical Hypnotherapy and Psychotherapy (AACHP), the Australian Counselling Association (ACA), The Newton Institute (TNI) and the Quantum Consciousness Institute (QCI). Here are some of the key points:

o You will be treated with respect

o You will receive competent an professional service

o You will receive a clear explanation of the service

o Your consent is essential prior to the service delivery

o You will receive clarity about the nature and limits of confidentiality

o You will receive a clear statement about fees

o You will be clear about outcome that you are working towards

o You will be shown respect for your cultural background, gender and religion

I, (print your name) , have read and understood the above consent form. I agree to these conditions for the Quantum Consciousness,

Past Live Regression or Life Between Lives session to be provided by Andrew Reay.

Signed Date

First Name Last Name