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Therapeutic Soundbath Consultation Form
Please complete this form before the soundbath to enable the facilitator to best support your needs. The information on this form is confidential between you and the facilitator, thank you
Email address *
Name *
Your answer
Tel.
Your answer
Contact in case of emergency: Name & Tel.
Your answer
Date of first session
MM
/
DD
/
YYYY
Are you under 18 years of age or a vulnerable adult? *
Required
Do you have any serious medical condition, recently had surgery/any medical procedure general special need? *
Required
Do you have any mental health challenges such as clinical depression, bipolar disorder, dissociative disorder, etc? *
Required
If you answered YES to any of the questions above, please provide additional details
Your answer
Would you be interested in hearing about other Therapies/Classes we offer via email? No problem if you’d rather not but we promise we won't bombard you with emails!
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