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Sound Healing Client Intake Form

Sound Healing Disclaimer:

Sound healing is a complementary wellness practice and is not a substitute for medical diagnosis, treatment, or professional healthcare. The practitioner does not diagnose conditions, prescribe medications, or interfere with the treatment plans of licensed medical professionals. Clients should consult their healthcare provider regarding any physical or mental health concerns. By participating in a sound healing session, you acknowledge personal responsibility for your own health and well-being health profile.

Name:

Date

Phone

E-mail

Are you OK being touched if necessary?

A
B

Do you have a pacemaker?

A
B

Are you a diabetic?

A
B

Do you have high or low blood pressure?

A
B

Any other serious illness or surgeries not mentioned above

Emotional Checklist

Select each statement that corresponds to the way you often feel.