PSYCH-K® with Angela Anderson

Release and Personal Data Record

Please read and sign the following. When you are done signing, please prepare for your first session by providing me with some personal information. Email your responses to questions 1-6 (below) to

DISCLAIMER:  I am not licensed as either a psychotherapist, counselor or a physician.  I am trained in PSYCH-K® Facilitation and am listed as a Preferred Affiliate on the PSYCH-K® Centre International website. I am not a certified PSYCH-K® Instructor. The difference between a certified instructor and a facilitator is that certified instructors teach the PSYCH-K® processes via in-person workshops with groups.  Facilitators offer 1:1, individual PSYCH-K sessions where we facilitate the processes so you can change your limiting beliefs.  In essence, we do not teach the PSYCH-K® processes to you, we facilitate them WITH you. It’s similar to going to learn how to give a massage from a certifying agent versus being a massage therapist and working with clients. I will refer you to a licensed professional should I feel it is appropriate, but, again, you must ultimately take responsibility for your own well being.

Please use the following information to prepare for your program. Email your responses before your first session to:

1. Top 10 limiting beliefs and their counterparts.

Please write out your top 10 limiting beliefs and their opposite counterparts. Example: “I don’t belong in this country” and “I belong in the United States and anywhere I chose. The universe is my home.”

2. Ideal Life

Please write out a statement of what you would like your life to look like.  Give some consideration to what your life’s purpose might be, and how that would show up in your ideal life.  Write this in first person present tense.

Take note of any thoughts or feelings that come up about why you believe it can’t be that way (i.e. – “I’m not good enough,” “I don’t deserve it,” etc.). 

2. Goals
Please also write out three specific goals for your life. They can be short-term or long-term.

Feel free to add as much detail as you like (what will you see? what will people be saying about you or to you? what will you be saying to yourself? how will you feel?) Again, take note of any thoughts or feelings that come up about why you believe it can't, won't shouldn't happen. 


3.  Blocks & Traumas

Please also make a list of between 3 and 10 events in your life that you would prefer had not happened. Try to narrow them down to two-minute events, and give them titles:  "My Biggest Humiliation" or "The Time in Third Grade When They Laughed at Me."  With out going into them or dwelling on them, think of how you would like to feel about these events or traumas instead (ex: peace and non-attachment).

4. Values

Please write a list of your values, using single words or short phrases (i.e. – Commitment, Sharing My Gifts, Safety, etc…).  Then put them in order of importance based on how you are living right now.  Please be honest – state the values that you are currently operating from.  Then make a separate list in the order you’d like them to be – you may also add or delete values.

5. Cast of Characters

Please let me know the names of your parents, siblings, former partners, anyone else you feel is significant in your past – whether they are living, married, etc. – anything you feel might be beneficial to our work together and feel comfortable sharing.  Anything you share with me - here and in our sessions – will be kept strictly confidential.  

6. Spirituality

If you are willing, please also share your religious/spiritual beliefs.  This is of course optional, but often useful.  Are you comfortable with the word God, or do you prefer another term?  Please know that I will respect whatever your beliefs are, and I ask this question so that our work will be compatible with those beliefs.

Thank you for your efforts on this.  This will provide us with a jumping off place - though we never know where the work will take us.  I greatly appreciate you for putting your trust in me – I will do all I can to support you in living the most joyful and abundant life possible.