Intake Information

Today's Date(Required)

MM slash DD slash YYYY

Full Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Other

Age(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Occupation

Email(Required)

Do you consent to be on my email list?

Yes

Emergency Contact

Phone

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical Information

Are you currently pregnant?

Yes

If yes, No. Weeks

Do you have a pacemaker?

Yes

Do you have any metal in your body?

Yes

Are you sensitive to fragrances or essential oils?

Yes

Have you experienced sound healing before?

Yes

Are there any instruments or sounds you DO NOT like?

Yes

Please specify:

Are you receiving other complimentary healing treatments?

Yes

Do you agree to receive energy healing during your session?

Yes

Do you give permission for hands on touch?

Yes

Do you have any medical conditions?

Yes

Please specify:

Are you taking any medications or supplements?

Yes

Please specify:

Do you have any allergies?

Yes

Please specify:

Have you had any recent injuries or surgeries?

Yes

Please specify:

Do you have any particular areas of concern?

Yes

Please specify:

Additional notes/comments of importance to know?

Do you have any expectations about your session?

What would you like to get out of your session?

Client Consent & Waiver Form

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

MM slash DD slash YYYY

Client Signature(Required)

Cancellation Policy

Please read carefully

Late Arrival

It is recommended to arrive 5-10 minutes prior to your scheduled appointment for any other necessary paperwork, discussion or setting yourself up.
If you arrive late we will do our best to accommodate you within the remaining time left, however you will still be charged at full price for the session.

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 serve weather or poor driving conditions make it difficult for you to attend your session, we will work with you to reschedule your appointment.

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

Client Name

Date

MM slash DD slash YYYY

Client Signature(Required)

Photography Permission

Please Read Carefully

Photograpahy Consent Release

Name

First Last

I hereby grant permission to Kristen Harper with Mindful Healing Sounds to take photographs of me during sound therapy classes or sessions. I understand that these photographs may be used for promotional marketing purposes, including but not limited to social media, website, printed materials, and advertisements.
I release and discharge Kristen Harper from any and all claims, demands, or causes of action that I may have due to the use of my photograph. I waive any right to inspect or approve the finished product that may be used in connection with my image.

I acknowledge that participation is voluntary and that I will not receive financial compensation for the use of these photographs.

I understand that my consent is voluntary and that I can withdraw this consent at any time by notifying Kristen Harper in writing.

By signing below, I confirm that I have read and understood the contents of this form, and I consent to the use of my photographs as described above.

Client Name

Date

MM slash DD slash YYYY

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.