Healing Treatments

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Emergency Contact *

Name & Relationship

First Name

Last Name

Emergency Contact *

Number

Country

(###)

###

####

Are you pregnant? Have you been pregnant or had a baby within the last 6 months?

Yes

No

Do you have any health conditions I should know about? *

Including mental and/or physical health, allergies or other concerns.

Yes

No

Do you have epilepsy? *

If yes, you are​ advised​ not to partake in Crystal Sonic Therapy.

Yes

No

Do you have any implants? *

For example: joint(s) replacement, metal plate(s), artificial pacemaker, cochlear implant(s).

Yes

No

Are you currently receiving care from any medical or health care practitioners? *

Yes

No

What is your primary reason for seeking treatment/ what are you hoping to achieve from our session together?

Please tick all that apply.

Relaxation

Stress Relief

Anxiety Relief

Pain Relief

Healing emotional wounds or trauma

Healing past/ current relationships

Spiritual Growth

Other

Have you experienced a Crystal Sonic Therapy session or Sound Bath before? *

Crystal Sonic Therapy

Sound Bath

Neither

Signed *

First Name

Last Name

Date

MM

DD

YYYY