*First Name:

*Last Name:

Address Line 1:

Service Date and Time (if known):

Address Line 2:

City:

State/Province:

ZIP/Postal Code:

*Email:

Home Phone:

Mobile Phone:

Fax:

Occupation:

Goals for Sessions:

Do you have knowledge of your divine purpose?:

Yes No

If "Yes", explain below.

Explain your knowledge of your divine purpose, if known:

How did you hear about us?

Please note any medical, emotional, spititual or other information of importance:

What is Divine Purpose Guidework?

The Divine Purpose Guidework program is designed to put you on track to fulfillment of your soul’s plan. During a Divine Purpose Guidework session I counsel you in connecting to Divine source and defining key elements of your soul purpose. As you tap into your inner spirit you access higher wisdom, clear foresight and effectuation of your Divine purpose with spiritual guidance.

Individualized soul work plans may include any of the tools for transformation and realization of your soul journey that are appropriate for you:

Releasing undesired attachments and non-serving thought processes
Cultivating confidence and decisiveness
Employing personal and guided meditation techniques
Spiritual clearing, practices and development
Establishing a practice of honoring sacred space
Activation of light channels for ascension and enlightenment
Working with spirit guides, angels and light beings
Developing practical skills for dreaming with purpose
Developing a personal mission statement
Clinical and transpersonal hypnosis
Past Life Regression
Spiritual Regression or Progression

Code of Ethics:

A responsible practitioner provides competent services with concern for the client’s welfare and respect for their dignity while maintaining professional integrity. The client’s well-being is my prime concern.

*Release Statement:

I have been advised of the scope of hypnosis practice and I give my full consent to receive sessions by Mary Catherine “Cathy” Miller for the purposes outlined in this intake form and for future purposes that I may request. I understand that hypnosis, NLP and life coaching are not replacements for traditional medical treatment or psychological/psychiatric services. I also understand that the practitioner does not treat, prescribe for, or diagnose any condition.

I am aware and understand that in some cases it may be necessary for the practitioner to respectfully touch my shoulders, hands, or wrists in order to assist me in relaxation. I give the practitioner permission and consent to do so in order to help me to establish a beneficial state of relaxation.

I understand that the success of my session depends greatly on my own ability and desire to create change in myself. I understand that results vary and that the above named practitioner may not guarantee results.

I will be on time for appointments and take responsibility for creating positive change as desired for my life.

_______________________

Type your name in the box below as your electronic signature attesting that you
have read and agree to the Release Statement above:

This is a required field.

Submit Your Message:

You MUST click the SUBMIT button to send your intake form entries.

Client Intake Form

Code of Ethics: