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New Client Intake Form

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Emergency name and contact number:*

Are you under the care of a healthcare provider? Write Yes or No...if Yes, please explain:

Current physical conditions / concerns:*

Current mental / emotional conditions: *

Medications / supplements:*

Pregnant or trying to get pregnant?*

Sensitive to sound / vibrations / touch / smells / any other sensitivities?*

Have or had any of the following?*

Chronic pain

Headaches / migraines

Arthritis

High / Low blood pressure

Heart conditions

Recent surgery / injuries

PTSD

Autoimmune condition

Neurological issues

Hearing sensitivity / tinnitus

Metal implants or medical devices / pacemaker

History of epilepsy or seizure disorder

Other

Sources of stress currently or recently*

Mood(s) in the last 2 weeks*

Calm / content

Anxious

Overwhelmed

Grieving

Numb

Depressed

Hopeful

Cycling of various emotions

Other

Emotional symptoms*

Sleep disturbance

Panic attacks

Fatigue

Difficulty focusing

Feeling stuck

Trauma triggers

Relationship stress

Addition issues

Other

Have you had sound healing with tuning forks placed on the acupuncture points or hands-on Reiki energy healing before?*

Yes

Touch preference:*

Sensitive areas on your body or areas you don't want to have hands or tuning forks place upon (besides the obvious genital area or directly on male or female breast area):*

Write 1-3 healing goals you'd like to see happen in your time with AcuTune Sound Healing (understanding that no wellness healing experience is ever, or rarely, one and done. Please remember these sessions are accumulative:*

Sleep quality*

Hydration*

Do you exercies? What type:*

How much time do you spend in nature a week?*

Allergies:*

Anything you'd like me to know?

Signature*

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Date*

Month

Day

Year