Please help us continue our research by taking 10-15 minutes answering the survey questions in Section 1 and Section 2. All answers are completely confidential and will be used strictly for statistical purposes. Your feedback and responses will be invaluable to quantifying the effects of past-life regression/experiences.

Your Name (Optional)

Your Email (Optional)

Section 1

1. What prompted you to seek out the past life experience?
 Curious/Personal Interest Memory or Knowing/Déjà vu Searching for Purpose Issues in this life Dreams Physical Issues in this life Impersonal Investigation/Dare/Part of a Class

2. Describe the nature of your experience:

3. Over what duration did your experience(s) occur?
 1 day 2 days 1 week 2 weeks 1 month 6 weeks 2 months 3 months 4 months 5 months 6 months Did not experience

4. How was your past life experience facilitated?
 Hypnotherapist Self-hypnosis Group hypnosis Regressionist Psychic/Mystic/Other readings Dreams Spontaneous Meditation/Breath Work/Yoga/Guided Imagery Other means

5. What sensory experiences were predominant?
 Immersive- all 5 senses Mainly sight Mainly sight and sound Mainly sight, sound, touch Mainly sight, sound, touch, smell Mainly sight, sound, and smell Mainly sight, smell and taste Vivid, but in other ways Did not experience

6. Describe the Emotional Experience.
 Heavy Light Heavy then lightened up Light then became heavy Medium Did not experience

7. How long has it been since your past life experience?

8. How many past life experiences have you had?

9. What is your age? (current lifetime)

10. What is your gender? (current lifetime)

11. What was your early religious/cultural upbringing?

12. What is your country of orgin?

Section 2

Please indicate your level of agreement or disagreement to each of the statements below. Respond as honestly as you can in regard to changes you have experienced as a direct result of past life recall or past life regression therapy. Responses cannot and will not be associated to any single individual and are gathered for statistical analysis only. Thank you for taking the time to help me in my research.

1. I have a larger sense of identity.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

2. My religious view or perspectives have widened.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

3. My views on life and death have changed for the better.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

4. I had a negative outcome as a result of past life regression.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

5. I experience less anxiety in my life.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

6. I no longer have an irrational or obsessive fear (phobia) that had plagued me previously.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

7. I had an emotional or psychological healing (alleviation of depression, sadness, anxiety)
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

8. I am able to handle daily stress with more ease.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

9. I have better self-esteem/self worth/self image.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

10. I have more confidence.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

11. I am happier and/or experience greater satisfaction in my life.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

12. I had a spiritual healing (abatement of a spiritual crisis or problem)
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

13. I feel less alone and more connected to the universe.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

14. Communication with my family and/or friends has improved.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

15. My personal relationships have improved.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

16. Others have noticed positive changes in me.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

17. I feel more closeness or inter-connectedness with other people.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

18. I had a physical or bodily healing (abatement of a physical condition or problem)
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

19. Circumstances in my life have changed for the better (moved, changed jobs, have changed relationships etc)
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

20. I have a greater sense of purpose.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

21. I have a greater sense of peace or contentment in my life.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

22. I have more control to influence my future that I previously believed.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

23. I have more faith in a positive or meaningful future.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

24. I view my current life from a more positive or meaningful perspective.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

25. Death no longer holds as much fear for me.
 Strongly Disagree Disagree Slightly Disagree Neither Agree or Disagree Slightly Agree Agree Strongly Agree

26. Did you have any benefits or deficits not mentioned in the survey? If you had a negative past life experience, please discuss here.­­­­­­­­­­­­­­­­­­­