Intake Form - Holistic Wellness - Mindful Healing Sounds

Sign Up for Your Private Sound Healing Session

NOTE: Registration for group classes are the first Saturday of every month at Root Yoga: https://www.rootdownandgrow.com/events/, and 3rd Saturday of every month at Hippie Soul Yoga, https://www.hippiesoulyogastudio.com/falconschedule.

Today's Date(Required)

Name(Required)

First Last

Age 18 or above?

Yes

Phone

Email(Required)

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Allow email correspondence with Kristen at Mindful Healing Sounds

Yes

Emails are used to reserve a time,location and specifics of your session with Kristen. You may always opt out of emails after your session, or remain on the email list to get updates about new theme offerings each month.

How did you hear about Kristen and Mindful Healing Sounds?

Please share any sensitivities to sounds or allergies to aromatherapy.

For instance, if you are sensitive to high-pitched noises, startle easily, and prefer softer, gentler sounds, or if you are allergic to certain essential oils used in aromatherapy. On the other hand, some individuals may prefer deep vibrations and the use of bowls placed on and around the body for more profound healing effects.

Have you experienced a sound bath before?

Yes

Do you give permission to have bowls placed on your body?

Yes

Do you have any particular areas of concern? i.e. Physical pain, illness, emotional healing that you would like Kristen to consider in your healing session?

If you are seeking healing for physical pain, illness, or wish to release blockages in your energy centers, please inform Kristen about the specific areas you would like to address. REQUEST AN ENERGY ASSESSMENT if you need more information about your particular energy balancing needs.

Do you have any metal objects in the body or a history of seizures you would like your practitioner to know about?

Yes

If you have pacemakers, pins, plates, cochlear implants, epilepsy, defibrillators, seizure disorders, or are in your first trimester of pregnancy, please consult your physician and let Kristen know in your comments below so your session can be guided with care.

Is there anything you would like your practitioner to know that might be helpful for your session?

What do you desire the most from your session?

Waiver

Please read carefully

Name:

First Last

I hereby give my consent to receive a sound-bath/healing and I acknowledge and agree that I am doing so at my own risk. My health and safety with respect to such services are my sole responsibility. My decision to receive services is voluntary, and I know of, understand and assume any and all the risks associated therewith. In exchange for receiving services for myself and on behalf of my heirs, executors, administrators and personal representatives, hereby waive, release, discharge and hold my therapist harmless from any and all liability for any and all injuries, including damages or claims relating to or resulting from my receipt of the services, now or in the future, foreseen or unforeseen.

Please take a moment to read each statement below and initial your understanding.

• If I experience pain or discomfort during the session, I will immediately inform my healer.
• I will not hold my healer responsible for any pain or discomfort I experience before, during or after the session.
• I understand that the services offered today are not a substitute for medical care.
• I understand that my therapist is not qualified to carry out a medical examination or provide a diagnosis and I agree not to interpret their comments as medical advice.
• I affirm that I have notified my therapist of all known medical conditions and injuries.
• I agree to inform my therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist's part should I forget to do so.
• I understand that this treatment is non-sexual in nature.
• I agree that my therapist may need to disclose my personal information if required to by law.
• By signing this release, I hereby waive and release my therapist from any and all liability, past, present and future relating to this treatment....

Client Name

Date

Client Signature(Required)

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Cancellation Policy

Please read carefully

Late Arrival

It is recommended to arrive 5-10 minutes prior to your scheduled appointment. If you arrive late I will do my best to accommodate you within the remaining time left, however you will still be charged the full price for the session. Try to give Kristen at least 24 hours notice if you need to reschedule. We can use your

No Show / Cancellation

• If you do NOT show up for your appointment you will still be charged at full cost for your session missed.
• In the event you need to cancel your appointment due to other circumstances 24 hours' notice must be given prior to your session.
• If you wake up on the day of your appointment ill, please contact us to reschedule your appointment.
• If you have any cold, flu, covid, persistent cough or breathing difficulties, please reschedule! I am happy to work with you!

Servere Weather Conditions

In the event that severe weather or poor driving conditions make it difficult for you to attend your session, I will work with you to reschedule your appointment.

These cancellation policies are subject to change at any time and are effective immediately.

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Client Signature(Required)

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Signature(Required)

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Client Feedback Form

My goal is to provide my clients with the best quality sound and energy healing experience as possible. I appreciate you taking your time and willingness to give honest feedback. Please rate each of the questions on a scale of 1-10 (Where 1 is poor and 10 is excellent.) and please provide any extra comments or suggestions that could improve yours or another's experience.

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The overall cleanliness and quality atmosphere of the space was professional and relaxing.