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intake forms

Treatment Intake Forms & Data Collection

Name *

First

Last

Email *

Health Concern *

ADD/ADHD
Anger
Anxiety
Cancer
Chronic Fatigue/Fibromyalgia
Circulatory Issues
Depression
Digestion
Eating Disorder
Endocrine Glands
Fear
Grief
Loneliness
Overwhelmed
Panic Attacks
Pain
Powerlessness
PTSD
Respiratory Issues
Sleep Issues
Substance Abuse
Other Issue

If Other Issue, please explain

Severity Before Treatment (Scale 1 - 10) *

10 is the most severe

Instrument or Technology used *

Alchemy Crystal Bowls
Chimes
Didgeridoo
Drums
Frosted Crystal Bowls
Melodic Instruments (Sansula, Hardood Drum, Freenote, Piano, Guitar, Sitar, etc.)
Sound Table / Lounge
Tibetan Bowls
Tuning Forks
Vibroacoustic Device (Devices that apply sound to the body: Bass Pod, Sound Belt)
Voice (Singing, Toning, Chant/Mantra, Overtone Singing, Guided Meditation)
Other Instrument

If Other Instrument, please explain

Details of treatment done *

Severity After Treatment (Scale 1 - 10) *

10 is the most severe

Comments from Client after Treatment.

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