Sound and Vibrational Therapy Intake Form Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone (###) ### #### Emergency Contact First Name Last Name Relationship Emergency Contact Phone (###) ### #### What is your primary reason for a sound and vibrational therapy session? * How would you describe your current state of physical health? What recurring physical symptoms or recent illnesses have you experienced? * Are you pregnant or suspect you might be pregnant? * Yes No Do you have any of the following? Pacemaker Hearing aid Metal in the body How would you describe your current state of mental health and emotional well-being? Do you have an intention for your session? Please share it here. Have you participated in sound or vibrational therapy or sound baths previously? * Yes No Is there anything else you would like to share? Thank you!- “Together in Sound we remember our wholeness.”
