Book your Divine Healing Session with Nicolas

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There is a Save and Continue option at the bottom of this form in case you need more time to fill it in.

Contact Details

First Name*

Last Name*

Birth Certificate Name*

Include all names on birth certificate

Do You Have a Non-English Pronounced Name? Non-English Pronounced Name?

For all non-english names (including your birth certificate name and currently used name) it is ESSENTIAL to send us a recording of your names pronounced as they would have been by parents at the time of naming. When recording, say the name at normal speed once, then three times more slowly at the same speed. If you don't speak the language then please ask someone that does to do the recording. Use the software Vocaroo (link below) or Speak Pipe to record the pronunciation of all non-english names. Then copy the link and add it below.

Record Your Name Pronunciations Here using Vocaroo/ Record Your Name using Speak Pipe

Share your Vocaroo/Speak Pipe link here

Alternatively upload your MP3 here

Occasionally Vocaroo/ Speak Pipe doesn't work for people. In this instance you can record your voice and save it as a MP3 and upload it below.

Max. file size: 512 MB.

Date of Birth*

Mobile/Cell phone number (inc country code)*

Landline phone number (inc country code):*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Time zone*

Email address*

Enter Email Confirm Email

About you

The reason we ask you all these deep questions is for us to get a clear understanding of your history, so if anything comes up in the session we can handle it accordingly. All the information you submit is strictly private and confidential.

Medical History*

Have you had any operations, accidents, illnesses, medication (Including psychiatric history)?

Yes

If yes please explain

Present health and medication.*

Please describe your present health including any medication you are taking regularly.

Mother’s Birth Certificate Name and Date of Birth*

Relationship with mother*

Describe your relationship with your Mother – whilst growing up & how it is now.

Father's Birth Certificate Name and Date of Birth*

Relationship with Father*

Describe your relationship with your Father – whilst growing up & how it is now.

Gestation and Birth*

Please state how long you were in the womb for and what was the circumstances of your delivery (e.g. premature, method of delivery etc.)

Drugs*

Have you ever taken recreational drugs (if yes, list them all)?

Have you ever abused alcohol?*

Yes

If yes please explain

Have you ever smoked?*

Yes

If yes please give further details

Dental Work*

Have you had any major dental work?

Yes

Dental Work Explained

If yes, please explain what and when it was

Do You Recall Any Emotional Traumas?*

Yes

Emotional Trauma Explained

Please list all emotional trauma you recall

Do You Have Any Allergies?*

Yes

Allergies Explained

Please list all allergies

Do You Have Any Addictions/Cravings?*

Yes

Addictions/Cravings Explained

Please list all addictions

Your Environment*

Describe your present home and family environment.

Your Occupation*

Describe your main occupation. Are you happy in it?

Diet*

Describe your diet.

Activity and Exercise*

Describe your level of activity and exercise.

Sexuality*

Do you feel your sexuality is flowing or is blocked in any way. Now or in the past? The reason we ask about your sexuality is that it's often an important indicator into how deeply your emotional separation programming is impacting your life force.

Menstrual Cycle*

Describe your Menstrual Cycle (e.g. Regular, irregular, PMS). If this question does not apply please write N/A

Practices*

Do you meditate or have a spiritual practice?

More About You

EQ-Emotional Intelligence*

How well can you feel the full range of human emotions e.g. fear, anger, despair, grief, anguish, terror, guilt, shame, hopelessness, rejection, abandonment, mistrust, unworthiness

Payment

If you have a PayPal account, we highly recommend you use this to complete your payment by signing in when you are given a choice to either use PayPal directly or your credit/debit card. This is where you will be given a choice to draw the funds directly from your PayPal balance or from the linked debit or credit card. This is to avoid any problems with a debit or credit card payment which can occasionally be caused by your bank’s fraud security system picking up the transaction to us as a new vendor, something that is outside of our control. Also in England the currency we use is British Pounds (GBP) if you are converting to your own currency NOT Euros.

Divine Healing Session (2 hours)

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Divine Healing Session with Nicolas