Vibrational Sound Healing Client Intake Form

Sound Healing Disclaimer

Sound healing is a complementary wellness modality designed to support relaxation, energy alignment, and emotional balance. It is not a substitute for licensed medical care, diagnosis, or treatment. I do not diagnose, prescribe, or interfere with any treatment plans from licensed professionals. Please consult with your doctor or mental health provider regarding any medical concerns.

By participating, you acknowledge that your health and well-being are your own responsibility, and you consent to receive sound healing as a supportive wellness practice.

Getting To Know You

First & Last Name *

Date of Birth *

Phone Number *

Preferred Contact Method *

Phone
Text
Email

Email *

Emergency Contact Name *

Emergency Contact Phone Number *

How did you hear about me / this session? *

Have you received sound healing or energy work before? *

Yes
No

If yes, what kind?

Chronic illness (please specify):

Anxiety / Panic / Overwhelm

Constant worry or fear
Anxiety or panic attacks
Overthinking or racing thoughts
Emotional overwhelm or reactivity
Difficulty focusing or staying present
Feeling spiritually disconnected

Sleep & Rest

Insomnia or disturbed sleep
Trouble staying asleep or falling asleep

Stress & Tension

Stress, tension, or burnout
Muscle tightness or physical pain
Headaches or body fatigue linked to stress

Emotional Well-Being

Depression or persistent sadness
Low self-esteem or self-doubt
Anger, frustration, or irritability

Energy & Motivation

Lack of energy or low motivation
Hyperactivity or difficulty sitting still
Feeling stuck, blocked, or ungrounded

Coping & Habits

Addiction tendencies (food, substances, sugar, etc.)
Obsessive thoughts or compulsive behaviors
Control issues or difficulty letting go

Body & Digestive Health

Digestive issues related to stress or emotion
Appetite changes (loss or increase due to mood)

Are you currently under the care of a healthcare provider? *

Yes
No

Are you currently taking medications? *

Yes
No

Are you comfortable with gentle, physical touch if needed for grounding or placing instruments (with consent)? *

Yes
No

Are there any specific physical or emotional conditions I should be aware of to better support you? *

Yes
No

If yes, explain.

Anything Else You’d Like Me to Know?

Which area of the body?

By signing below, I acknowledge that I have read and understood the disclaimer above. I give my informed consent to receive sound healing and understand it is a supportive practice, not a replacement for professional medical or psychological care.

Client Signature *

Date *