Client Intake Form

Please fill out the following form.

Full Name

Date of birth

Year

Month

Day

Phone

Email

Address

Emergency Contact - Name, relation, and phone number

What do you hope to gain from your session?

Describe the problems you wish to address. Include any medical diagnoses, treatments you’ve tried and their effectiveness.

What other healing modalities have you tried? How was your experience? Were they effective?

Do you have a pacemaker?

Yes

No

Do you have metal plates, rods, screws or pins?

Yes

No

Are you pregnant or trying to get pregnant?

Yes

No

If you answered yes to any of the questions above, please supply additional information.

List any allergies and sensitivities (drug, chemicals, food, animals, scents).

List any surgeries you feel are relevant.

List any major accidents or traumatic events you feel are relevant.

What is your stress level?

Extreme

Moderate

Low

Unsure

What do you do to relax?

What do you do to take care of your physical body?

Are there any other issues you would like to address?

How did you hear about Sound Healing & Wellness?

What brings you Joy?

Are you ready and open?

I declare that the info I’ve provided is accurate and complete.

By proceeding, I confirm that I have throughouly read and fully understand and agree to the terms and constions outlined in the below link.

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Signature

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Date

Year

Month

Day

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