Past Life Regression Client In-Take Form Please note that all fields are required. Your Full Name Your Email Address Your Phone Number Your Birth Date Please provide more information if you have ever been treated for an emotional problem What do you desire to experience in a past life? What outcomes do you desire? Are there any persons or behaviours in this life prompting you to have the experience? What are your spiritual/religious inclinations? Any additional informaton you want to add or I should know? By submitting this form you agree to the information below. I realise that Jaco Pieterse is a hypnotist and not a medical doctor or psychologist, and that he cannot diagnose disease, prescribe, or treat medical conditions or serious disorders. I understand that the past life experience might be information from the subconscious mind which is presented as a metaphor, not unlike the process of dreaming. Additionally, I should continue any present medical treatment and consult my regular physician for treatment of any new or old illnesses. I also agree that Jaco Pieterse or myself may terminate this relationship at any time for any reason whatever.