Er.

Sanjay Rishabhdev
+919771463355
PLR Facilitator, Hypnotherapist,
+919852189831
Reiki & Spiritual Healer
mail: sanjay.plrt@gmail.com

Mobile:

E-

CLIENT HISTORY SHEET

Note: Feel convenient enough to give all the information correctly as it is used in finding the
CORE ISSUE for your present problem and clue to your Past Life thereby serving you better.
Use back side of sheet to give extra information if you need to do so. We ensure the respect for
& confidentiality of your information.
Date: ___/___/____
CLIENT'S NAME:___________________________________
Birth date:___/___/____
Age:___
Client's Address:

Occupation or school:____________________________________________
Home Phone no.___________
Cell Phone no.___________
E-mail: ________________________________
Referred by:___________________________________________________
Marital Status:
Single __; Married __; Partnered__; Divorced __; Remarried__; Widowed __
Spouse/Partner Name: ______________________________________
His/Her Occupation: _____________________
Please list all children you have had. First list those currently living with you.
Then draw a line and list others who do not live with you on a full-time basis
.
Name
Relationship Age
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Grade or Occupation
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CLIENT QUESTIONNAIRE
Date ____________________
Your answers to the three sections on this page are very important. Please use the first
section to tell me your reason(s) for requesting my services. Use the second section
to describe ways you want your life to have changed for the better when we finish
working together. Then use the third section to tell me about areas in your life
where you are generally pleased about how things are already working.
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Have you been in therapy before? Yes [
]; No [
]
If yes, please briefly summarize (when, how long, goals, results):
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If yes, please provide the name, address and phone number of your most recent
therapist. I will not contact him/her before I obtain a signed release from you.
Therapist name:_____________________________________________________
Address _____________________________________________________
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Telephone (____)_______-________
Pregnancy and Birth History
To the extent known, please complete the following:
Describe any complications that occurred during your mother's pregnancy with you.
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Describe any complications that occurred during delivery (e.g., prematurity,

postmaturity, length of labor, special procedures, low APGAR score, etc.).
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_____________________________________ Birth Weight ____________
How long after birth did your parents take you home? _______________
Early Temperament
Describe your temperament during the first six months (i.e., sleep patterns,
colic, eating patterns).
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Developmental History
To the extent known, please list any developmental milestones that occurred early
or late. (Walking, talking, toilet training, etc.)
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Medical History
List significant sicknesses, operations and injuries. Note history of frequent ear
infections, ruptured eardrums, tubes. Include the age when they occurred and
severity. Please pay special attention to head injuries, any loss of consciousness,
convulsions, or very high fever.
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Did anyone in your immediate family or their close relative have any of the following:
Nervous tics Yes ____ No ____ Who ______
Seizures (epilepsy) Yes ____ No ____ Who ______
Depression Yes ____ No ____ Who ______
Bipolar Disorder Yes ____ No ____ Who ______
Thyroid problems Yes ____ No ____ Who ______
Other emotional problems Yes ____ No ____ Who ______
Hyperactivity/ADHD Yes ____ No ____ Who ______
Learning problems Yes ____ No ____ Who ______
Language problems Yes ____ No ____ Who ______
Mental retardation Yes ____ No ____ Who ______
Similar problems to you Yes ____ No ____ Who ______
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Does any disease run in the family? If so, what? _______________________________

Indicate any medications you are currently taking and the prescribing physician.
(Include dosage and the reason for taking it.)
Medication Dose Physician Reason for taking
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Indicate any medication you have taken in the past few years for more than a
month and the prescribing physician. (Indicate dosage and the reason for taking it.)
Medication Dose Physician Reason for taking
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Approximately when was your vision last examined? _______
Results __________________________________________________________
Approximately when was your hearing last examined? ______
Results __________________________________________________________
Other special medical tests (EEG, CAT scan, MRI)
Name of Test _________________________ Date ____________
Results __________________________________________________________
Have there been any previous psychological, psychiatric or neurological
evaluations? Yes [ ]; No [ ] If yes, please list the year and provider.
Please attach any pertinent reports.
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Height: ___' ____" Current weight: ____ Range during last 12 months: _______
Please describe current and past tobacco use: __________________________________
_________________________________________________________________ ______
Caffeine use: # cups coffee/day _____; # caffeinated 12 oz. soft drinks/day _____
History of alcohol use (1 beer = 6 oz wine = 1 oz hard liquor):
Your current range per week: from ___ to ___ drinks.
Past range per week (at your highest usage): from ___ to ___ drinks.
When was this? ___________________
Have you ever been in an accident or had a ticket for driving under the influence?
Yes [ ]; No [ ] If yes, please give details. __________________________________
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If you have ever had moving traffic violations, please describe:
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Social/Emotional/Behavioral History
Please list your personality characteristics, both positive and negative:
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School History
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List previous schools, colleges/universities, technical schools attended:

Years School Degree (if any) Approx. GPA
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Describe any learning/behavioral/social difficulties you had while attending school:
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Describe any special services you received in school or privately (resource room,
tutors, remedial reading, speech therapy, etc.):
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Did you ever repeat a grade? ______ When? ____________
What was the problem? ____________________________________________________
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Complete this sentence regarding yourself as easily and quickly as you can:
a) My life would be everything I want it to be if only

b) However, what is preventing this from happening is

Supplemental History Form

Work History
Current job title, length of employment,
attitude about your work

Brief history of previous employment

Physical Health History

Significant past illnesses
Significant injuries, both chronic and
resolved
Prior surgery

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Current health problems

List all current medications. If you
recently stopped taking any medications,
please list those.

Prior Therapy History

Briefly describe prior or current therapy,
when this took place, and the primary issues
addressed.
If currently in therapy, does your therapist
know youre exploring past life issues? If
not, please address this with your therapist
prior to our meeting.

Prior history of trauma

Emotional abuse or neglect
Physical abuse
Sexual harassment or abuse
Other traumatic events such as natural
disasters, car accidents, witnessing events
which were traumatic such as a violent
crime or accident.
If yes to any of the above, did you get
therapy or counseling? Was it helpful?

Family of Origin
Briefly describe your parents, their ages,
whether they are still alive and if not when
they died; list siblings whether alive or
dead, their ages, and anything you see as
significant in the life of the family, whether
because it was very positive or very
challenging.

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Childhood and adolescence:

Briefly describe your school history and
education with the year of your high school
graduation, college attendance and degrees,
and other specialty training.
Summarize your dating during adolescence
and beyond.
Describe hobbies, clubs, and other leisure
activities.
Describe how you see yourself fitting in
with your family of origin.

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Religion and spirituality

Briefly summarize your religious
upbringing and your attitudes about it; what
role does religion currently play in your life
as distinct from your current spiritual
beliefs and practices.
Reincarnation and Past Life Therapy
When and how did you become interested
in the topic of reincarnation and past lives?
What kind of books, if any, have you read
on the subject?
Have you previously had any past life
therapy or regression therapy? If so, when,
with whom, and what were the results?
Have you had any spontaneous experiences
which seem like they might have been
memories from other lifetimes?
Are you drawn to particular time periods in
history or particular geographical locations?
Any aversion to particular time periods in
history or particular geographical locations?

Prior Experiences with Hypnosis

Has anyone ever tried to use hypnosis with
you in the past? If so please describe the
results.
Have you ever witnessed hypnosis being
used, whether professionally or as
entertainment? If so, please describe
(especially your reactions to what you saw).
Please describe any concerns or
apprehensions you may have about
hypnosis.

Other paranormal experiences (your own or those of someone close to you)

Near-death experiences
Pre-cognitive dreams
Deja-vu experiences
Contacts with angels, spirit guides, etc.

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Have you had any negative paranormal

experiences? Please describe.
Motivations for exploring past life therapy at this time
Please describe any specific issues, themes,
or relationships that you would like to
explore.
If there are any issues or topics you wish to
avoid, please describe them.
If relevant, does your partner or spouse
know that you wish to explore past lives?
Does this have the support of the significant
people in your life?

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