Waiver Form

 

General Intake Form and Waiver

Personal Information:

Name:___________________________________________Date of Birth____________ Address:______________________________________________________________________ City:________________________State:____________________________Zip:_____________ Email:_________________________________________Phone:_________________________ Occupation/s:_________________________________________________________________

 Physical Activities:_____________________________________________________________

Emergency Contact:

 Name:__________________________________________________ Relation:_____________ Phone:_______________________ Email:__________________________________________

Medical Information that you feel comfortable sharing:

Have you had a professional Sound Therapy Session before? Y/N

Level of stress: (5 - Highest, 1 - Lowest) _______________

What is the main source of stress in your life?_____________________________________

 Do you have sensitivity to sound or vibration? Y/N ____________________________

 Do you have difficulty lying on your front or back? Y/N Please explain:______________ ______________________________________________________________________________

Any accidents or surgeries in the last 2 years? Y / N _______________________________

Any implants? (Pacemaker etc).? Y / N_________________________________________

Are you Pregnant? _______If YES, how far along are you? ____________________

Please check all that apply:

____ I am unwell and taking medication, If YES what medication __________________

 ____Lymphatic conditions: swollen gland, nasal congestion or Lymphedema.

 ____Joint health: stiffness, arthritis, sacroiliac discomfort, TMJ or other.

____Bone conditions: osteoporosis or other

 ____Headaches or migraines, If YES, are they chronic   Y /  N

____Recent injury or accident: whiplash, sprain, bruise or other.

____Numbness or tingling paired with sharp pain

 ____Tendonitis or bursitis.

____Diabetes.

____Circulatory conditions: high blood pressure, varicose veins or blood clots.

 

Please review and initial the following statements:

I, being the client or receiving party and Payee of the Sound Bath session

The Practitioner, being Rachel Holding at Holding Holistics

____If I experience pain or discomfort during the session, I will immediately inform my practitioner so that any pressure or techniques applied can be adjusted to my level of comfort. I will not hold my practitioner responsible for any pain or discomfort I experience during or after the session.

 ____I understand that the services offered today are not a substitute for medical care. I also affirm that I have notified my practitioner of all known medical conditions and injuries so that they may adjust to my needs. I understand that there shall be no liability on the therapist part should I forget to do so.

 ____Sound Therapy is contraindicated for certain medical conditions. I affirm that I have discussed all my known medical conditions with the practitioner and completed the information on this consent honestly. I understand that I should see a physician or qualified medical specialist for any mental or physical ailment of which I am aware. I agree to keep the Practitioner updated as to any changes in my medical/physical conditions that might affect my ability to safely receive my Sound Session.

 ____By signing this release, I hereby waive and release Holding Holistics and my practitioner Rachel Holding from any and all liability, past, present and future relating to Holding Holistics.

 ____I understand that should I cancel an appointment less that 24 hours before the scheduled time I am subject to a fee equal to the half cost of the missed appointment. If I cancel an appointment in under 3 hours of the scheduled time, I am subject to a fee equal to the full cost of the missed appointment. If the appointment was booked under package, it will be voided or redeemed in lieu of the fee. I also, understand all sales are final, no guaranteed refunds, approved changes to this rule at practitioner’s discretion.

*In general, sound therapy is done while fully clothed. This is your session and you should be as comfortable as possible, wear comfortable clothes. *Sound Therapy is a therapeutic, professional service. Inappropriate or sexual conduct of any kind, initiated by any party will not be tolerated. If uncomfortable for any reason, the client or practitioner may ask to end the session, and the session will end. I have received this policy statement and have read and agreed to all of the policies therein:

 Print Name:________________________

    Signature:  _____________________

              Date:___________