Walk-in Questionnaire Application Form

"*" indicates required fields

Contact Information

Name*

First Middle Last

Birth Certificate Name*

Please include all names

Date of Birth*

Email address*

Enter Email Confirm Email

Postal address*

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

Mobile number*

Please include international dialling code.

Timezone or your current location in the world*

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

For all non-english names 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.

Have you experienced or are experiencing any of the following:

Please answer all as fully as possible.

A change (or changes) in your personality?*

Depression, feelings of inexplicable grief or of wanting to die?*

Allergies and autoimmune diseases?*

Body pains, joint pains, arthritis symptoms?*

Sudden changes in relationships with friends, family, partners and pets?*

Feeling really sick, crazy or unwell after spending much time with your family?*

Being so out of the body that you crash into walls?*

Wanting to wear hats all the time?*

Severe illness, accident, coma, concussion or emotional shock?*

A feeling like everyone is asleep around you, why are they doing all this weird stuff, can't they see what's really going on?*

Unable to express what you really feel and think in the English (or your native) language?*

Wondering 'why don't they tell the truth?'*

Appearing to be ruthless/rude/cold to other people?*

Feeling like an alien on this planet*

A complete lack of emotional attachments to parts of your past, as if it was a movie?*

A desire not to speak coming from the sense that you can't convey what you really want to say?*

Hypersensitivity to electromagnetic frequencies, computers, TVs, overhead power lines, mobile phones & masts etc.?*

A disparity between what you know to be the truth and your external reality?*

A change in personal preferences such as foods, clothing, colours and lifestyle? change in personal*

Schizophrenia, feeling like you are going crazy or feeling like you are many different people at once?*

The feeling like you are here to do something very special but can't remember what it is?*

Exhaustion and fatigue that are out of proportion to your level of exertion?*

Hypersensitivity to others feelings and thoughts?*

Feeling really spaced out and ungrounded?*

Memory loss of big chunks of your life or of what you said yesterday?*

A sense of completion with life, saying goodbye to friends and family even though you do/did not know why?*

Epileptic-like seizures?*

A feeling of newness and wonder about the world?*

Feeling like who are these strangers who think they are my family?*

A strong urge to tell the truth no matter what?*

Clumsiness or poor coordination*

Wondering who are all the aliens here and what are they doing?*

An inability to find the food you really want to eat?*

A feeling of needing to change your name - my name is not my name?*

Feeling androgynous?*

Is there anything else you think your practitioner should know?

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Would you like to join the Mailing List of the Center for Conscious Ascension?*

By selecting Yes, you agree to receive informative and helpful emails about trainings, webinars, free resources, products and special offers that may support you. You will only receive emails once or twice a month.

Yes Please

No Thank You

Walk-in Questionnaire Application Form

Contact Information

Have you experienced or are experiencing any of the following:

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