Sound Being Intake Form

Sound Being Intake Questionnaire Form

* Indicates required field

Name *

First

Last

Date of Birth *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact *

How did you hear about Sound Being? *

Have you received energetic or alternative therapies in the past? *

Yes No

How has your experience(s) been with other energetic therapies if applicable? *

Do you have difficulty with sound or touch? *

Yes No

Do you have any surgical implants or contraindications I should know about? (Please see contraindications list attachment below) *

Yes No

If yes, please explain: *

*Do you have any allergies, or sensitivities to scent, including essential oils? *

Yes No

If yes, please explain: *

I acknowledge that I have downloaded, read, and understand the contraindications and disclaimer below. I understand that the energetic techniques used are not a substitute for the medical care of a physician, nor are they in any way medical advise. I have consulted with a medical doctor and if any contraindications are present and I take full responsibility for my health and engagement in this energetic technique as relaxation. *

Yes

Questions or comments: *

Submit

Please download Sound Being Consent, Contraindications & Disclaimer Forms here:

Sound Being Forms
File Size:	101 kb
File Type:	pdf

Download File

*For clients who choose in person sessions with Rae in Twain Harte, Ca please be advised that pets live on premises. If you have any allergies or difficulties with cats or dogs, setting up a distance session or a session at another location may be a better option for you.