Service Agreement and Intake form

Today's Date*

Date

Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Cell Phone*

Area CodePhone Number

E-Mail*

example@example.com

How do you generally feel about yourself? What are your strengths and weaknesses? Do you wish you could change something about yourself?*

What are your current Stress Factors?*

Do you take any prescription or nonprescription drugs and for what reason? Are you dependent on any of them?*

How many Alcoholic Beverages do you consume in a week? Please describe your current and past relationship alcohol.*

Briefly outline your spiritual beliefs. Word/name for your higher power? *

Do you practice any type of meditation? If not, would you like to? Please explain why or why not.*

Please describe the activities or places that make you feel the most "like yourself"*

Please describe your reason for seeking healing services? What you hope to achieve?*

Anything or other information helpful for me to know. (Please add something special & unique about yourself as well.)*

Please share any critical or relevant medical history.... (Major medical events, current diagnosis's, Medications, if not previously outlined, recent surgeries. Also, any treatments you have already undergone related to your current reason for coming to On The Lighter Note)*

Do you have a Pacemaker? (Critical question... I cannot use the sound table if you have a pacemaker)*

As a child, did you experience any abuse or trauma?*

YesNo

Type of abuse:*

Please describe your abuse or trauma. Please include your age at the time of the incident (s):*

WAIVER and TERMS of SERVICE

In receiving Galactic Frequency Healing from Rev. Pepique Stout, dba On The Lighter Note:

I understand that no guarantees have been made to me as to the effect of such services.

I agree to keep an open mind and expand my consciousness to the best of my abilities to accept new beliefs or concepts that may lead to the evolution of my spiritual awareness.

I understand that my healing is ultimately my responsibility. Rev. Stout, healing team at On The Lighter Note and the healing instrumentation are simply to assist me in my own healing and self-discovery.

I understand and acknowledge that in no way are these services to be construed by me as the diagnosis or treatment of disease or mental health counseling but rather as an aid to balancing my energy and to possibly improving my general physical, emotional, mental and spiritual wellbeing.

I understand that energy healing and/or vibration therapy are not substitutes for medical treatment, medications or mental health counseling and it is recommended that I concurrently work with a qualified health care professional for any condition I may have.

I understand that I may experience improved physical, emotional, mental and spiritual wellbeing.

I am aware that my provider does not diagnose illness and does not prescribe medical treatments.

I understand and accept the inherent risks of being in close physical proximity to another person even when they have recently tested negative for covid 19 and, I will express any concerns about physical distancing to the provider and request to receive healing treatment at a distance that meets my comfort level.

If I experience any discomfort during the session, I will immediately communicate that to the practitioner so the treatment can be adjusted.

I give full consent for Rev. Pepique Stout gently place his hands and/or tuning forks on my physical body. The areas I consent to being touched include hands/wrists, feet/ankles/lower legs, head, heart center, navel and back. If I am uncomfortable with any of these locations, I will immediately or preemptively communicate that to the practitioner so the treatment can be adjusted.

I release, waive, and indemnify Rev. Pepique Stout, and On The Lighter Note, including its employees, officers, owners, from any accidents, injuries, damages, or death for participating in this Energy Healing and/or Vibration Healing session. I am at the legal age which is 18 years old or older and I am mentally capable of signing this waiver.

I have read and understand the above service agreement*

YES

Client Signature*

By signing you agree to the conditions stated above

On The Lighter Note

Client Information

Personal Information

Medical Background

Social History