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

Which Service Are You Participation In? (Required)

For Addiction Recovery Support Services Only (Required)

How did you hear about On The Lighter Note (Optional)

How would you currently describe your overall well-being?

What are some current sources of stress in your life?

What are your intentions or goals for this session?

Is there anything important you would like me to be aware of to help support your experience?

Do you have any medical conditions, injuries, sensitivities, or physical concerns that you would like to share?

Are you currently using any medical devices (such as a pacemaker) or have any conditions that may be affected by electromagnetic fields or sound or vibration?

If yes, please describe:

Are you currently taking any medications or substances you would like us to be aware of for your comfort or safety? (Optional)

Is there any personal history or life experience you feel is relevant to your current journey?

Briefly describe your spiritual or personal belief framework (if you wish):

Do you currently practice meditation or mindfulness?

Client Consent and Liability Waiver

I understand that services provided by On The Lighter Note LLC and Rev. Pepique Stout are intended for personal wellness, relaxation, spiritual exploration, and personal development purposes only.

I understand that these services are non-medical and non-clinical and are not intended to diagnose, treat, cure, or prevent any medical, psychological, or substance-related condition.

I acknowledge that these services are not a substitute for licensed medical care, mental health services, or addiction treatment, and I am responsible for seeking appropriate care when needed.

I understand that no specific outcomes or results are guaranteed, and that individual experiences may vary.

I acknowledge that sessions may include sound, vibration, tuning forks, gong resonance, and other sensory experiences. I agree to inform the practitioner of any sensitivities, medical conditions, or concerns prior to the session.

I understand that I may stop or modify the session at any time and agree to communicate any discomfort immediately.

I voluntarily assume all risks associated with participation in these services, including physical, emotional, or sensory experiences.

I release and hold harmless On The Lighter Note LLC, Rev. Pepique Stout, and any representatives from any and all liability, claims, or damages arising from my participation.

I acknowledge that I am at least 18 years of age and legally capable of providing consent.

I have read, understood, and agree to the terms above

Some sessions may involve light, optional physical contact such as placement of hands or tools on areas including hands, wrists, feet, ankles, head, center of chest, navel or back.

I have read, understood, and agree to the terms above

Date

Client Signature

By signing you agree to the conditions stated above

On The Lighter Note

Client Information

Service or Session Information

Personal Context (Optional)

Wellness & Safety Information (Optional)

Personal Background (Optional)

Client Consent and Liability Waiver

Physical Contact Consent