Client Information Profile

Please use the ONLINE form below to fill out and submit your Client Information Profile.  You can also DOWNLOAD & PRINT OUT the form and either send it in or bring it with you to your session.

Download the Client Information Profile, Click Here

CLIENT INFORMATION PROFILE

All information is completely confidential and will not be shared without written consent.

PLEASE FILL OUT YOUR PROFILE

Your Contact information - *Required Information

Best Contact for Phone Number - please include Country code if outside USA

What are the best Days and Time for you to have a Session?


Please answer the following questions to help with your Session.

1. What do you want or what outcome are you seeking to get from your Session?

2. What will this outcome do for you? How will it affect your life?

3. Describe any accidents or injuries you recall. Have you spent any time in the hospital?

4. Do you currently have any physical pain or discomfort?

5. Are there any people in your life that you are in conflict with?

6. What do you know about your birth experience? 

7. What do you know much of your family history/heritage?

8. If you could go back in time to witness an historical event, it would be:

9. If you could go back in time to meet an historical figure, it would be:

10. List of questions, you would like to ask your Sub-Conscious/ your Higher Self/ Divine.

11.  List of five or more casts of characters, people important in your life now


YES-NO QUESTIONS: Indicate ONE answer ONLY by selecting Yes, No or Maybe. If requested, please give details.

1. Do you believe in the concept of past lives?
YesNoMaybe

2. Do you believe in the concept of karma?
YesNoMaybe

3. Do you believe that you have lived before?
YesNoMaybe

4. Have you had/do you have any distinctive birthmarks?
YesNoMaybe
If yes, please describe them and where they are

5. Do you have/have you had persistent, chronic headaches that cannot be treated by either conventional or alternative medicine?
YesNoMaybe

6. Do you have/have you had any other persistent, chronic pain that cannot be treated by either conventional or alternative medicine?
YesNoMaybe

7. Have you had/do you have severe over or under weight problems?
YesNoMaybe

8. Have you had/do you have areas of your body where you cannot stand to be touched?
YesNoMaybe

9. Have you had/do you have areas of your body where you cannot stand to wear tight fitting clothing?
YesNoMaybe

10. Have you had/do you have serious problems with finances such as compulsive spending or worry about money?
YesNoMaybe

11. Have you had/do you have serious problems controlling your anger (always impatient, criticizing, losing your temper or regretting outbursts)?
YesNoMaybe

12. Have you been/are you constantly plagued with the inability to trust yourself, others, the universe, or God (constantly plagued by fears of abandonment and betrayal)?
YesNoMaybe

13. Have you had/do you have inappropriate fears or phobias?
YesNoMaybe

14. Have you been/are you diagnosed as having obsessive - compulsive disorder?
YesNoMaybe

15. Have you been/are you diagnosed as having any depression - anxiety?
YesNoMaybe

16. Have you been are you diagnosed as having multiple personality disorder?
YesNoMaybe

17. Have you been/are you diagnosed as having any physical, mental, or emotional addictions (to food, drugs, sex, medicine, abusive relationships)?
YesNoMaybe

18. Have you had/do you have recurring dreams / nightmares?
YesNoMaybe

19. Have you ever seen yourself as another person or in a historical time in a dream?
YesNoMaybe

20. Have you had / do you have any medical problems that appeared suddenly and inexplicably (in particular, any allergies or phobias)?
YesNoMaybe

21. Have you had / do you have any other medical problems (physical, mental, or emotional) that cannot be solved?
YesNoMaybe

22. Do you have skills and abilities normally requiring study that come naturally to you?
YesNoMaybe

23. Have you ever found yourself in an educational setting where you came to learn about a particular subject and found that you already knew more than the teacher?
YesNoMaybe

24. Do you have a compelling or overwhelming interest in a particular topic that began in your childhood?
YesNoMaybe

25. Have you had / do you have an absolute compulsion to do something or go somewhere that is completely out of context of your life today?
YesNoMaybe

26. Have you ever been to a place before - that you have never before visited in this lifetime and knew that you had been there before?
YesNoMaybe

27. Have you ever just known details about certain places, people, or things which you would have no way of knowing about otherwise?
YesNoMaybe

28. Have you ever felt totally at home or abnormally anxious in a place you have never been?
YesNoMaybe
If so, did you feel at home or abnormally anxious?  And where did this take place?

29. Have you had/do you have either a strong attraction for or aversion to certain types of foods you have never before eaten?
YesNoMaybe

30. Have you had/do you have either a strong attraction for or aversion to certain types of climates that you have never experienced before in this lifetime?
YesNoMaybe

31. Have you had/do you have either a strong attraction for or aversion to certain types of clothing (casual vs. formal, tight fitting vs. loose, etc.)?
YesNoMaybe

32. Have you had/do you have either a strong attraction for or aversion to certain types of furniture?
YesNoMaybe

33. Have you had/do you have either a strong attraction for or aversion to a certain group of people which is not explainable by the circumstances of your present life?
YesNoMaybe

34. Have you had/do you have either a strong attraction for or aversion to certain religions that you have never before studied or practiced?
YesNoMaybe

35. Have you had/do you have any habits that others close to you consider odd or peculiar and that you have no control over?
YesNoMaybe

36. Have you had/do you have any mannerisms that others close to you consider odd or peculiar and that you have no control over?
YesNoMaybe

37. Have certain sights ever triggered feelings in you that you cannot account for by your
experiences in this lifetime?
YesNoMaybe
If yes, what sights?

38. Have certain sounds ever triggered feelings in you that you cannot account for by your experiences in this lifetime?
YesNoMaybe

39. Have certain smells ever triggered feelings in you that you cannot account for by your experiences in this lifetime?
YesNoMaybe

40. Have you kept / do you keep antiques or other collectibles in your home from a particular historical period?
YesNoMaybe


Acceptance & Signatures:

If you do allow your name to be used in future publications of a book, how would you like it to be stated? Example: John D, J Doe, or Bob, Brooklyn

Client Signature: Sign below

Date: 11/13/2019

Signed: Dr. Rajiv Parti Date: 11/13/2019