Participant Intake & Experience Form

Please fill out the following form.

Full Name

Date of birth

Year

Month

Day

Phone

Email

Address

Emergency Contact - Name and phone number

Have you experienced a sound bath or sound healing session before?

Yes

No

If yes, what was your experience?

What inspired you to join the Release Retreat?

What would like to let go of, or open up to during the weekend?

Is there anything you'd like us to know to help create a supportive experience for you (e.g., trauma sensitivity, sensory needs, social comfort)?

Do you have any of the following conditions? (select all that apply)

Cardiovascular issues (high/low blood pressure, heart conditions)

Epilepsy or a history of seizures

Hearing sensitivity (e.g., tinnitus, hearing aids)

Metal implants - rods, screws, pins (please specify location)

Pregnancy (if yes, please provide trimester)

Pacemaker

Other (please specify)

Please specify

Do you have any history of trauma, PTSD, or sensitivity to certain sounds?

Yes

No

Prefer not to say

Do you have any other medical conditions, physical limitations, or recent injuries we should be aware of (e.g., joint pain, vertigo, trouble getting up)?

Are you comfortable with light touch and the direct application of a tuning fork to send gentle vibrations to specific areas, if applicable?

Yes

No

Do you have any questions or concerns regarding the sessions?

Do you have any additional goals, intentions, or hopes for this retreat that you'd like to share? (This could be something physical, emotional, spiritual, or simply a feeling you're hoping to experience.)

What brings you Joy?

Are you ready?!

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

Photographs may be taken to capture the experience and may be used for future promotional materials, including social media and website content. Images will be shared with participants as memento of the experience.

By checking the box, I consent to the use of photographs in which I may appear for promotional purposes and to receive access to shared event photos.

I prefer not to be photographed and kindly request that images of me are not used in promotional materials.

By proceeding, I confirm that I have throughouly read and fully understand and agree to the terms and constions outlined in the following link https://www.mysoundhealth.ca/disclaimer

Open in a new tab to view

Signature

Signature field is empty.

Date

Year

Month

Day