Consent Form – Counselor, Hypnotherapist, and Reiki Master

Click this link: Printable PDF of the Form

Name *

First

Last

Email *

Address, City, State/Country, Zipcode *

Phone Number *

Date of Birth (mm/dd/yyyy) *

Marital Status *

Number of Children *

Occupation *

Hobbies/Interests *

Do you have any ongoing medical problems? Symptoms? Treatments? *

Fears or Phobias? *

Have you ever been hypnotized before? *

Do your have a meditative or spiritual practice? *

Current state of health? *

Research Consent *

I agree
I decline/do not agree

Research and Publication Consent - The information I am about to recall about my past lives, life between lives or multi-dimensional self may be used for research and/or publication by Claudia Jean Hilton and/or The Michael Newton Institute. I assign to Claudia Jean Hilton the right to use my words and anonymized identity for valuable consideration, the sufficiency of which is acknowledged here. This may include written publications or speaking engagements to enlighten others about their purpose on earth knowing my name and any personal identifying information is not used other than age, gender, and general occupation. I understand that my confidentiality will be completely honored.

Full Name Digital Signature acknowledging choice for Research Consent *

List of Questions You Would Like Answered and Areas Explored *

Cast of Characters *

List significant people in your life so far. Please include relationship and interesting characteristic of each individual.