Date *

Email *

Phone *

Address *

Country

Address Line 1 *

Address Line 2

City *

State *

ZIP Code *

Emergency Contact and Phone *

Have you ever had a sound healing? *
YesNo

Do you have a particular area of concern? *

Health Information *

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

PregnantCancer or terminal illnessHeart condition/pacemakerConcussion or head injury in the last 6 monthsRecent broken bonesObesityEpilepsyCurrently taking medicationsAllergiesOther

Other Health Information

If other, please describe:

Any sounds/instruments you do not like? *

Are you sensitive to fragrance (incense/oils)? If so, which ones? *

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

How did you hear about us? *

Client Signature *

Date *

Parent or Guardian if Client is Under 18

Date