Soul Based Sessions with Becca
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Session Agreement Form
Coaching Questionnaire
with Joseph Shields
Please fill out this form before your next session.
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Name
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First
Last
Birthday
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Time of Birth
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Place of Birth
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Email
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Phone Number
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What is your main purpose or reason for choosing to do sessions?
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What is the desired outcome or result you are looking for?
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Briefly describe your spiritual or religious beliefs or your life philosophy.
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Check all that your are interested in addressing:
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Chronic Pain
Self Esteem
Angry Feelings
Spiritual Guidance
Guilty Feelings
Sexuality
Anxiety/Stress
Relationship
Life Purpose
Unwanted Habits
Past Life
Lack of Energy
Prosperity
Sleep
Weight/Body Image
Fears
Other
Family History
How would you describe your relationship with your mother or maternal guardian? Check all that apply for how you felt your mother figure was for you
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Supportive
Loving
Over Controlling
Abusive
Distant
Angry
Depressed
Weak
Addiction Issues
Dismissive/Avoidant
Anxious/Nervous
Ambivalent/Indecisive
Disorganized
Scattered/Self-Involved
Try to be a Friend Parent
Broken Promises/Let You Down Parent
Insecure or Cowardly Parent
Obedience and Perfection Parent
How would you describe your relationship with you father or paternal guardian?
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Check all that apply for how you felt your father figure was for you.
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Supportive
Loving
Over Controlling
Abusive
Distant
Angry
Depressed
Weak
Addiction Issues
Dismissive/Avoidant
Anxious/Nervous
Ambivalent/Indecisive
Disorganized
Scattered/Self-Involved
Try to be a Friend Parent
Broken Promises/Let You Down Parent
Insecure or Cowardly Parent
Obedience and Perfection Parent
Are You Adopted?
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Yes
No
It's complicated
Number of Sisters
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Number of Brothers
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What position in the sibling line up are you? Such as middle, oldest, youngest etc.
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Were there any miscarriages, stillbirths, abortions or child deaths in the family? If so please explain.
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Are there any other things coming up for you that you would like to note like core beliefs, fears or blocks that you are holding you back in life? If so please explain.
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PLEASE READ AND SIGN:
Like the practice of medicine, hypnosis, self-hypnosis and regression are not absolute sciences. We personally know of no cases or have any knowledge of any case on record where a person has been harmed in any way by hypnosis, self –hypnosis, hypnotherapy, meditation or regression. We do know of thousands of cases where individuals have benefited from these experiences. It is necessary as a general practice to have everyone taking part in Joseph Shield’s services to sign this disclaimer.
I have read and agree to the following:
I understand that results vary because all individuals are unique and that Joseph Shields may not guarantee results.
Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counseling and that Joseph Shields 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 shoulder(s), hand, wrist, or forehead in order to assist me in relaxation. I give her the permission and consent to do so in order to help me establish a beneficial state of hypnosis.
I am the co-therapist in this session and I agree to participate in each session to the best of my ability. I am in control of my session and I am free to terminate any or all sessions at any time should I choose to.
There is a strict confidentially policy. All my sessions will be honored and kept in full confidence between Becca Lynn and myself. This same confidentially is respected when working with minors under the age of eighteen.
I Agree to be on time for my appointments and to allow at least 24 hours advanced notice should I need to cancel or reschedule a session.
I give my full consent to receiving hypnosis/hypnotherapy and or coaching sessions with Joseph Shields.
To be more successful in reaching my goals, I know it is important for me to:
Accept responsibility for myself, my choices and actions, and that I, knowingly or unknowingly, create them. (Note: Responsibility means the ability to respond)
Realize that blaming anything or anyone, including myself, is totally useless and that the only person that can take charge of my life is me.
Recognize my thoughts, feelings, perception and actions have a direct effect on my life and I can ultimately choose my own experience.
Be an active and willing participant in my hypnotherapy/coaching session and as a co-therapist I am engaged in reaching my goals through the process of the sessions and in my homework assigned.
Print Name for Signature
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First
Last
Thank you so much for filling out this form. Everything in this form and in our session is kept completely confidential. And as always, please let me know if you have any questions at all.
I'm looking forward to continuing our journey together towards your freedom and happiness!
Thank you,
Joseph
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