Public Survey Step 1 of 4 25% EARTh (The Earth Association for Regression Therapy) Regression Therapy & Past Life Regression Therapy Public Survey Form The purpose of this survey is to evaluate the effectiveness of Regression Therapy in addressing a wide range of physical, psychological and spiritual issues. As Past Life Regression Therapy is an aspect of Regression Therapy, so we also wish to include those experiences. Data from the survey will be examined to identify areas in which client feedback either indicates, or contra-indicates, the use of Regression Therapy as a therapeutic intervention. So we seek volunteers that have experienced either of these therapies to complete the form and be reassured that your identity will not be disclosed. Participation is purely voluntary and you will be able to withdraw from the survey at any time by simply closing the web page. The form can be completed in less than 15 minutes Any personal details offered will be stored securely, treated as being confidential to you and will not be shared with any other parties outside EARTh. Statistics may be drawn from the form and used for research purposes into the effectiveness of Regression Therapy only. After submitting this form we will send you an email offering an opportunity to tell your story and have it displayed on a webpage without disclosing your identity. This alone can add to the therapeutic effect of any therapy that has been undertaken, yet it is on a purely voluntary basis only. To complete the survey, questions marked * must be answered Please tick box to confirm as appropriate1001 Are you aged 18 or over?* Yes 1002 May we use this information for research purposes?*(Your Identity will not be disclosed) Yes 1003 Have you experienced a ‘Past Life Regression Therapy’ or ‘Regression Therapy’ to address a personal issue?* Yes 1004 Did you work with an EARTh therapist? Yes Check the list of EARTh Therapist following this link: EARTh Therapist Directory Please select the reason for your visit to the regression therapist.*Tick 'Physical Symptoms' box to display a range of common answers and select one that applies to you. If none apply to you, just untick the 'Physical Symptoms' box to close that section. Continue by ticking the 'Psychological Symptoms' box. Tick any that apply to you or untick the 'Psychological Symptoms' box if none apply. Continue by ticking the 'Spiritual Interests' box. Tick any that apply to you or untick the 'Spiritual Interests' box if none apply. If there was a further reason for visiting the regression therapist that is not already selected, then please tick the 'Other' box and briefly give your reason in the box that appears. Otherwise leave the box unticked. Please check at least one option. 2100 Physical Symptoms 2200 Psychological Symptoms 2300 Spiritual Interests 2400 Other Physical Symptoms* 2101 Allergies 2102 Auto Immune System 2103 Back/spine/neck pain 2104 Bones/Joints 2105 Cancer/tumour 2106 Diabetes 2107 Digestion 2108 Fatigue 2109 Head /headaches/migraine 2110 Heart/Chest 2111 Hormonal problems 2112 Lungs/breathing 2113 Panic Attacks 2114 Problem with Body Organ 2115 Skin problems 2116 Sleeping Problems/Insomnia Psychological Symptoms* 2201 Addictions 2202Anxiety 2203Curiosity 2204Depression 2205 Dreams/Nightmares 2206 Eating Disorders 2207 Family Ancestry 2208 Hallucinations Audio/Visual 2209 Hyper-sensitivity 2210 Identity Issue: Dissociation 2211 Loneliness/Loss/Abandonment 2212 Low Self Esteem 2213 Meaning or Purpose lost 2214 Obsessive Thoughts 2215 Past Life Memories 2216 Personal Development 2217 Phobia 2218 Post-Traumatic Stress Disorder 2219 Relationship Issues 2220 Remote session for other person 2221 Removing Intrusive Energy 2222 Sexual Problems 2223 Spirit Release/Possession 2224 Spiritual Crisis 2225 Stress 2226 Success/Work/Money Spiritual Interests* 2301 Akashic Records Visit 2302 Ancestor Connection 2303 Extra Terrestrial Encounters 2304 First Incarnation on Earth 2305 Future Life Progression 2306 Incarnation on Other Planet 2307 Life Between Lives 2308 Soul Group Connection 2309 Soul Purpose Discovery 2310 Soul Retrieval 2311 Spiritual Development 2401 Other - describe in box*Based on your selections from the columns above, please select your original motive for attending therapy first, and then put any others into an order of those that had most importance to youOriginal Motive ……………………. 2nd ………………………………….. 3rd ………………………………….. 4th ………………………………….. 5th ………………………………….. Physical Symptoms - if none, then please skip to ‘Psychological Symptoms’2601 If you had any physical symptoms, were they diagnosed by a doctor/medic, psychiatrist?Prefer not to answerYesNo2602 Please give brief explanation, whether diagnosed or not2603 Did symptoms change after session(s)? Please tell us how much?Prefer not to answerWorseNo differencePartly disappearedMainly disappearedCompletely disappeared2604 Any CommentsPsychological Symptoms – if none then please skip to ‘Spiritual Interests’2701 If you had any psychological symptoms, were they diagnosed by a clinical psychologist, psychiatrist, psychotherapist?Prefer not to answerYesNo2702 Please describe2703 Did symptoms change after session(s)? Please tell us how much?Prefer not to answerWorseNo differencePartly disappearedMainly disappearedCompletely disappeared2704 Any CommentsSpiritual Nature – if none please skip to ‘Treatments’2801 Did you have an experience that you believe to be of a spiritual nature?Prefer not to answerYesNo2802 Please describeTreatmentsWere you receiving any other treatments at that time? 2901 MedicalPrefer not to answerYesNo2902 TherapyPrefer not to answerYesNo2903 OtherPrefer not to answerYesNo2904 Please describe treatments below2905 Please describe any further issues addressed that are not already described in this form 3001 What did you notice about the symptoms immediately following the sessions?Prefer not to answerWorseNo differencePartly disappearedMainly disappearedCompletely disappeared3002 Any Comments3003 What do you notice about the symptoms now?Prefer not to answerWorseNo differencePartly disappearedMainly disappearedCompletely disappeared3004 Any CommentsPlease state length of time since sessions3005 When did you have the last session?(can be approximate)Prefer not to answerLess than 3 months ago3 months to 1 year ago1year to 3 years ago3 years to 5 years agoOver 5 years ago3006 In what way have the sessions made a difference for your life today? Please explain3007 Number of Sessions(can be approximate)Please select1 session only2-5 sessions6-10 sessionsover 10 sessions3008 How long did the therapy last?(can be approximate)Please select1 session onlyUp to 3 months3 months up to 1 yearover 1year 4001 NameIt is optional to give your name yet it will not be disclosed. First Last 4002 AgePlease selectPrefer not to answer18-3031-60Over 614003 GenderPlease selectMaleFemale4004 NationalityPlease selectAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe4005 Relationship StatusPlease selectPrefer not to answerSingleMarriedDivorcedWidowedSeparatedCivil partnershipCo-habitingIn a RelationshipOtherPrefer not to say4006 Religious UpbringingPlease selectPrefer not to answerAgnosticAtheistBuddhistCatholicHinduHumanistJewishOrthodoxMethodistMuslimProtestantSikhOtherPrefer not to say4007 OccupationPlease selectPrefer not to answerAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRegression TherapistRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTherapistTransportation/LogisticsOther4008 EducationPrefer not to answerDid not attend schoolHigh school to age 16 or equivalentCollege over 16 or equivalentB.A. or B.Sc. Degree or equivalentMasters Degree or a higher equivalentOther4009 Email Address* Enter Email Confirm Email Are you human ?Please select ‘Previous’ if you wish to review your answers on each page. Press ‘Submit’ to complete your submission This iframe contains the logic required to handle Ajax powered Gravity Forms.