Mary Catherine “Cathy” Miller /
Certified Hypnotist, Past Life regressionist,
Life Between Lives Practitioner
FAX 888-394-4054

NurseHealer/Divine Purpose GuideworkTM Client Intake Form

Please answer as many questions as possible; but you may leave any blank that you feel uncomfortable answering.

Name: / Date:
Address:
City/State/Zip: / Occupation:
Phone (home): / Phone (work):
Phone (cell): / Email:
Goal(s) for session(s):

Do you have knowledge of your Divine Purpose? __Yes (Explain) __No

Which elements would you like to include in your Divine Purpose Guidework?

___ Releasing undesired attachments

___ Releasing non-serving thought processes

___ Cultivating confidence and decisiveness

___ Personal meditation techniques

___ Guided meditation

___ Spiritual clearing

___ Spiritual practices

___ Spiritual development

___ Sacred space

___ Activation of light channels for ascension and enlightenment

___ Working with spirit guides, angels and light beings

___ Dreaming with purpose

___ Developing a personal mission statement

___ Clinical or transpersonal hypnosis

___ Past Life Regression

___ Spiritual Regression or Progression

How did you hear about us?

Please note any medical, emotional, spiritual, 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.

Signature ______Date______

(You may write on the back or attach added sheets if more space is needed for answers.)

Guided Meditation * Hypnosis * Past Life Regression * Life Between Lives

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