Sound Healing Intake Form

We understand that the personal information you share with us is sensitive and confidential. We take all necessary precautions to protect your information from unauthorized access, use, or disclosure.

We will only use your personal information to help tailor sound healing sessions for you. We will not share your personal information with any third parties without your consent, except as required by law.

If you have any questions or concerns about the confidentiality of your personal information, please do not hesitate to contact us.

Name *

First Name

Last Name

Email *

Phone *

Country

(###)

###

####

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? *

What makes you the happiest in your life currently? *

What would you most like to change or improve regarding your overall wellness? *

Are you now or regularly experiencing any of the following?

Please select all that apply

anxiety

stress

trouble sleeping

depression

anger

inability to relax

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

relationship issues

difficulty communicating with others

distrust of your intuition or inner wisdom

other (please explain below)

Have you ever received sound healing therapy or participated in a sound bath before? *

What do you hope to gain from your sound healing session? *

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. *

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. *

Do you have any expectations, concerns, or anything else you would like to share with the practitioner? If so, please detail below. *

Consent *

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 healer's instructions and to refrain from drinking alcohol or using recreational drugs at least two hours before or during a sound healing session. I agree to arrive to the session without being under the influence of alcohol or recreational drug. I give my consent to receive sound healing from Christopher Parker. 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. Please enter your full name and today's date before hitting "Send".

Thank you! I look forward to seeing you soon!