Ceremonial Sound Bath - Intake Form

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This short Client Intake Form helps me understand any relevant health considerations and/or cultural needs, so I can support you safely and respectfully during your session. Your privacy is important to me. Your personal information is confidential and will not be shared.

Date of Session

What inspired you to seek Sound Therapy and how did you learn about me?

What would you like to achieve in the session or session plan?

So that I ( your Sound Therapy Practitioner) may best support your needs, please select Yes or No to the following statements;

I am in the first trimester of pregnancy

I suffer from epilepsy/seizers

I have mental health challenges such as anxiety or depression

I have metal plates in my body

I require life-saving medication

If you selected Yes to any of the above statements, please provide more detail in the box below, or advise any health conditions including major surgeries or injuries you may have ( including year and site of injury) that I should be aware of.

Are there any cultural needs or sensitivities that I need to be aware of when planning your session?

Yes
No
Prefer to discuss

to Is the

If you selected ‘Yes’, please feel free to share in the text box below any cultural needs or sensitivities you feel are important for me to know. If you selected ‘Prefer to discuss’, I’ll reach out before your session so we can talk about how I can help you feel held and supported during the session.

Is there anything else I need to be aware of before we get started?

Please read the following statement and sign or write your name below:

I understand the practitioner doesn't diagnose illnesses or prescribe treatment and I will inform the practitioner of my current condition at each visit.

Name

First

Last

Signature

Clear Signature

Date

Intake Form

Vibe Align Sound Therapy

Christine Harris