Regression Intake ⋆ Jyll Hoyrup

Thank you for helping me get to know you a little bit better by filling out this Regression Intake Form. We will spend some time talking before we begin your Session. What is the Date of your Session?

Name *

First

Last

Email *

Phone Number including Country Code *

Age *

Have you ever experienced any type of Hypnosis? *

Yes
No

What type of Hypnosis? What was your experience? The outcome? If not applicable type N/A. *

Have you ever experienced any type of Energy Healing? Which Modality? *

What is your main reason for having this Regression Session? *

FOR HIGHER SELF AND AKASHIC RECORDS SESSIONS: Please list your specific questions about Life, Career, Health, Relationships, Life Purpose, Awakening, Ascension, etc. (we will have time for 5-10 questions - list in order of importance). For Group Regression, put N/A. *

Name and relationship of important people in your life (Spouse, Significant Other, Parent, Sibling, Children, Best Friend, etc.). For Group Regression, put N/A. *

Health Status/Conditions/Diagnoses. For Group Regression, put N/A. *

Current Medications. For Group Regression, put N/A. *

Do you agree to use a wired (plugged in) pair of headphones or headset? Wireless, Bluetooth, Airpods won't work. *

I agree
I don't agree

Do you agree to NOT USE CAFFEINE for 4 hours prior to your session? *

I agree
I don't agree

Alcohol Use/Frequency *

Do you agree to NOT USE ALCOHOL for 24 hours (1 day) prior to your session? *

I agree
I don't agree

Cannabis Use/Frequency *

Do you agree to NOT USE CANNABIS for 24 hours (1 day) prior to your session? *

I agree
I don't agree

Prescription Drug Use/Frequency (Antidepressants, antipsychotics, anxiolytics, mood stabilizers) *

Do you agree to NOT USE Prescription Drugs within 4 hours of your session? *

I agree
I don't agree

Unprescribed Drug Use/Frequency (methamphetamine, cocaine, dexamphetamine, nicotine, MDMA/ecstasy, opioids, heroin, barbiturates, GHB, ketamine, magic mushrooms, LSD) *

Do you agree to NOT USE Unprescribed Drugs for 72 hours (3 days) prior to your session? (copy) *

I agree
I don't agree

TERMS OF PURCHASE: I give Jyll Hoyrup of Jyllicious L.L.C. consent to perform meditative hypnosis session(s). I agree that actual sessions, either in person or online, and the outcomes of these hypnosis sessions are not guaranteed to produce successful results. Jyll Hoyrup is not healing me—I'm being given a chance to heal myself. I agree that the audio/video footage and information gathered in my session may be used at Jyll Hoyrup's discretion for marketing and educational purposes, including but not limited to blogs, vlogs, social media, etc. Personal information will be edited out for client privacy. I declare that Jyll Hoyrup of Jyllicious L.L.C. is free of any legal action taken by me, related to my hypnosis session(s). Receiving an unsatisfactory session, inability to be hypnotized or gather the desired information, technological issues (including but not limited to audio/video malfunctions), etc., are possible outcomes of this experience and do not warrant a refund or legal action to recoup session fees. I understand Jyllicious L.L.C. maintains a No Refund Policy. Sessions that are cancelled or rescheduled by me less than 24 hours before my session are NOT eligible for a refund. No Shows are not eligible for a refund. Sessions that are canceled more than 24 hours before the scheduled time are refunded 50% of the price of the Session. I also agree to set an intention to have a beautiful, successful session where I manifest the outcome for myself that brings my soul exactly the kind of healing that I need in this moment. I acknowledge that the success of this session is my divine responsibility.

I agree
I don't agree