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Phone

Address

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Address

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City

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Birthday

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Day

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Gender

Please mark all that apply and provide any additional health information that you'd like us to know:

Pregnancy or planning to become pregnant

Cancer or terminal illness

Heart condition/pacemaker

Concussion or head injury in the last 6 months

Recent broken bones

Obesity

Epilepsy

Currently taking medications

Other

If other, please describe

List any goals that you may have our session today and for your long term health:

Goals:

Consent

I grant my practitioner permission to use light touch and the application of weighted forks and/or sound bowls on my body. I am aware that I may verbally revoke this permission before or during my session at any point.

Yes

Signature

Signature of Client: (or Parent/Guardian if client is under 18)

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Today's Date

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Disclaimer

Sound healing sessions are intended to support relaxation, self-awareness, and energetic balance. While sound healing can be a powerful complement to professional counseling or medical treatments, it is not a form of medical treatment, psychotherapy, or trauma therapy.

Participation in sound healing is not a substitute for professional mental health care, diagnosis, or treatment, nor are they intended to diagnose, treat, cure, or prevent any condition or illness. Sound healing should not be relied upon as health, medical, psychological, or other professional advice of any kind or nature. If you are experiencing medical issues, acute psychological distress, or symptoms of a mental health condition, please consult a doctor or licensed therapist.

I have read the disclaimer and agree.

Yes, I agree to the disclaimer.

No, I do not agree to the disclaimer.

Please Select Your Service

Individual Sound Healing Session$200

Individual Biofield Tuning Session$200

Sound Healing for Integration (Post-Therapy or Ceremony)$200

Biofield Tuning Relationship Session $250

Biofield Tuning Adrenal Rhythm Reset$450

Client Intake Form

Thanks for visiting!

Please share a little about you...

Address

Please mark all that apply and provide any additional health information that you'd like us to know:

List any goals that you may have our session today and for your long term health:

Consent

Signature

Disclaimer

I have read the disclaimer and agree.

After two-weeks, we will invite you to participate in a paid membership. Please see the information and benefits for a paid membership here.