White Owl Wisdom
Past Life Journeys
B.A., LMT, Certified Reiki Practitioner
Certified Past Life Soul Regression Therapist
PO Box 814
Hotchkiss, CO 81419
NAME: (Last) (First) (M.I.)
City State Zip Country
HOME PHONE: WORK PHONE:
CELL PHONE: EMAIL:
DATE OF BIRTH: AGE: MARITAL STATUS:
NAMES/AGES OF CHILDREN:
If you smoke or drink alcohol, how much and how often?
Have you previously been in psychotherapy/counseling? How long?
Have you experienced a Past Life Regression before?
How did you hear about Dina and White Owl Wisdom?
Have you read any books about past life regression?
The information I am able to recall about the spirit world and/or past lives during my sessions may be utilized by Dina D'Antonio-Smithson for research, writing, and speaking engagements to enlighten others as long as my name and address and any other identifying information is NOT used. Nothing said, printed, or produced by Dina D’Antonio-Smithson is intended or meant to diagnose or prescribe a remedy for a physical, emotional, spiritual, or mental condition -- or to take the place of a licensed psychotherapist or licensed physician. Should I decide to use any ideas, tools, procedures, exercises or other suggestions that surface during the session I will do so at my own risk or under the supervision of a medical doctor or other healthcare professional.
I understand that I am totally responsible for my own healthcare and maintenance.