Name
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First Name
Last Name
Email
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Date of Birth (DD/MM/YYYY)
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Where are you from?
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Have you recently had any surgery or medical procedure?
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Yes
No
If yes, were/are there any complications?
Yes
No
Do you have any serious medical conditions or general special need?
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Yes
No
Are you being treated for or do you currently have any of the following? (Please select all that apply):
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Are you pregnant?
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Yes
No
If yes, how many weeks?
Do you have or have you had frequency triggered epilepsy or any seizures which you believe is sound triggered?
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Yes
No
Do you have metal implants, plates, a pacemaker or other metallic items in your body? (not tooth fillings)
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Yes
No
Are you sensitive to fragrances or essential oils?
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Yes
No
If you answered YES to any of the above questions, please provide additional details below:
Have you had any past experiences with sound healing or energy work?
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Yes
No
Are there any sounds or instruments that you DO NOT like?
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Yes
No
If YES, please provide additional details below:
INTENTION SETTING: What are your intentions for your session? (Please select all that apply):
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If Other, please specify below:
Is there anything else you would like to share regarding your intentions for your session that will help me to tailor the experience to better accommodate your needs? If YES, please provide additional details below:
FOR RETREATS AND WORKSHOPS ONLY: Do you have any allergies or dietary restrictions we should be aware of?
Yes
No
If YES, please provide additional details below:
Is there anything else that you would like to share with me?
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Yes
No
If YES, please provide additional details below:
How did you hear about us?
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If Other, please specify below:
I hereby consent to participate in sound and/or energy healing therapy and I understand that the purpose of this therapy is to promote relaxation and healing. During the session the practitioner may use gentle sounds and vibrations on and/or around my body. I understand that the practitioner is certified and does not diagnose illness, disease, or physical or mental disorders, nor do they prescribe medical treatments or pharmaceuticals. I acknowledge that these sessions are not a substitute for medical examination or diagnosis, and that it is recommended I see a doctor or physician for those services. I understand that I alone am responsible for informing my doctor, if necessary, I am receiving these sessions and inquiring as to whether or not they may adversely affect my health condition. I acknowledge that there may be risks associated with the therapy, and I assume full responsibility for any reactions or consequences that may result from my participation.
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Today's Date
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MM
DD
YYYY
