intake forms Treatment Intake Forms & Data Collection View Reports Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Health Concern *ADD/ADHDAngerAnxietyCancerChronic Fatigue/FibromyalgiaCirculatory IssuesDepressionDigestionEating DisorderEndocrine GlandsFearGriefLonelinessOverwhelmedPanic AttacksPainPowerlessnessPTSDRespiratory IssuesSleep IssuesSubstance AbuseOther IssueIf Other Issue, please explainSeverity Before Treatment (Scale 1 - 10) *10 is the most severeInstrument or Technology used *Alchemy Crystal BowlsChimesDidgeridooDrumsFrosted Crystal BowlsMelodic Instruments (Sansula, Hardood Drum, Freenote, Piano, Guitar, Sitar, etc.)Sound Table / LoungeTibetan BowlsTuning ForksVibroacoustic Device (Devices that apply sound to the body: Bass Pod, Sound Belt)Voice (Singing, Toning, Chant/Mantra, Overtone Singing, Guided Meditation)Other InstrumentIf Other Instrument, please explainDetails of treatment done *Severity After Treatment (Scale 1 - 10) *10 is the most severeComments from Client after Treatment.Submit View Reports
