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Biofield Tuning Intake Form

For all new clients, please fill out this client intake form. Your information is private and will not be shared.

If you have filled this form out in the last year, you may exit this window.

Click the button below to complete your intake.

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Question 1 of 13

Name (First, Last)

Question 2 of 13

Email address

Question 3 of 13

How did you hear about us?

Question 4 of 13

What is your age? (If you are under the age of 18, you will need parent/guardian consent)

Question 5 of 13

What are your goals for working together?

Question 6 of 13

Are you pregnant or planning to become pregnant? (Please note: Biofield Tuning and pregnancy should be done with caution, as there is a potential for detox symptoms after a session)

A

Yes

B

No

Question 7 of 13

Have you had a head injury within the past 3-6 months?

A

Yes

B

No

Question 8 of 13

Are you experiencing any of the following?

(Select all that apply)
A

Heavy metal toxicity

B

Active cancer or cancer treatment

C

Seizures

D

None of these

Question 9 of 13

Do you have any concerns or questions you'd like to address before we start working together?

Question 10 of 13

If you would like to provide me with any other information about you that could be helpful for me to know, please write below:

Question 11 of 13

What is the best way to reach you?

(Select all that apply)
A

Email

B

Text

Question 12 of 13

Please list your emergency contact name, relationship and phone number.

Question 13 of 13

Session Consent: The sessions provided are not intended to replace the advice or care of a licensed physician or psychologist. Sessions with my practitioner are not intended to diagnose, treat, or cure disease, but to support the body’s natural ability to heal itself. By signing this form, I understand that there is a possibility for physical and/or emotional discomfort from sound healing/energy work and if it lasts greater than 3 days, I should notify my practitioner.

I understand that hydrating with water before and after sessions helps my body to support itself.

A

I agree

B

I'm a minor and will need my parent/guardian to provide consent.

Confirm and Submit