Integral Sound Healing form Integral Sound Healing Intake Form About YouYour Name(Required) First Last Date of Birth Day Month Year Your Address Street Address Address Line 2 City Post Code Your Email Address(Required) Email Address Confirm Email Address Phone(Required)Preferred Method of ContactEmailPhoneGetting to know youPlease answer the following questions as honestly as you can so I can begin to understand your intentions for our sessions together.On a scale of 1 to 10 (1 is extremely dissatisfied and 10 is extremely satisfied), how would you rate your current satisfaction with your overall wellness?(Required)10987654321What makes you the happiest in your life currently?(Required)What would you most like to change or improve regarding your overall wellness?(Required)Are you now or regularly experiencing any of the following?(Required)Please select all that apply anxiety stress trouble sleeping depression anger difficulty relaxing lack of mental or emotional clarity spiritual challenges creativity blockages not feeling grounded trust issues fear general insecurities dissatisfaction with life guilt or shame power or control issues self esteem / self confidence issues relationships issues difficulty communicating with others distrust of your intuition / inner wisdom other (please explain below) Please tell me more if you selected "other" aboveHave you ever received sound healing therapy or been to a sound bath before?(Required)YesNoWhat do you hope to gain from your integral sound healing session?(Required)Do you have any physical limitations, injuries, recent surgeries, or mobility challenges that we should consider when planning your session? If so, please detail below.(Required)Do you have any metal implants in your body? If so, please detail below. Some of the vibrations during sound healing sessions could cause uncomfortable sensations in areas of metal implants. We will work together to avoid this.(Required)Hearing : Do you wear hearing aids? Do you experience tinnitus? Any other hearing issues I should be aware of?(Required)Do you have any expectations, concerns, or anything else you would like to share with me? If so, please detail below.(Required)ConsentPlease enter your full name and today's date before hitting Submit to indicate you agree to the following:(Required)I understand that sound healing is a complementary therapy and is not a substitute for medical care. I agree to provide accurate information about my health and to inform my sound healer of any changes in my health status. I also agree to follow my sound practitioner's advice and to refrain from drinking alcohol or using recreational drugs at least two hours before or during a sound healing session. I give my consent to receive sound healing from Katrina Berry. I understand that sound healing may cause me to feel relaxed, calm, or sleepy. I also understand that sound healing may not be effective for everyone. I release and hold harmless from any and all claims or liability of whatsoever kind or nature arising out of, or in connection with, my sound healing session(s). By entering my name and date below and submitting this form, I agree to all of the above. Δ
