Appointment Request & Membership Application Intake Form

Appointment Request & Membership Application Intake Form

Our Tranquillum House Membership is required for in-person immersion services and retreats. Annual standard membership starts at $11.11, sustaining level at $100. As we wish to eliminate financial barriers in service, please contact us at OurTranquillumHouse@gmail.com to apply for limited scholarships if cost is prohibitive.
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date/time/location of birth (required for Astrology services)
What date and time work best for you?
Please add another specific date and time, if the above selection is not suitable.

MonthDayYear
Date
Hour MinutesAM/PM Option
What are your primary concerns & which services are you interested in? Reference Link to OTH services: https://www.zeffy.com/en-US/ticketing/26eb948b-1b09-494f-8a5a-eca981efb541
Would you like to be notified about updates and upcoming retreats?

YesNo
Please select any symptoms you experience

HeadacheFaintness / DizzinessTightness in jawWeak body partsSmokingNervousness / AnxietyPoor AppetiteExcessive UrinationGrinding of TeethHeavy feeling in limbsBlurriness of VisionConstipationLoose bowel movementsIrritated bowel / IBSPains in heart / chestIndigestionInsomniaFatigueCold in hands / feetLower back / hip painShoulder / neck painCarpel tunnel syndromeMenstrual IrregularitiesOther
Consent

I consent to treatment for myself (or my minor child), and understand that the services provided by the practitioners/healers/ministers of Our Tranquillum House is intended to enhance relaxation, connect with divinity, and increase communication within my body.

I understand that these services are not a substitute for medical treatment or medications. I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan.

I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that I may experience ‘healing reactions’ during the 24 to 48 hours following the services provided.

I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. I do, however, give the practitioner consent to use my case history and results without using my name. I understand that only the practitioners/healers/ministers of Our Tranquillum House will have access to information in my file to enhance my healing.

I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless both the practitioners of Our Tranqillum House and the facility/location where the services are provided.

I agree to the terms and conditions set out by this consent form and certify that the above information is true and correct. I agree to donate for in-person and distance sessions, should I request them. Submission of application is considered consent.
Please select any areas below you would like improvement in

Negative self talk, self sabotageBelief in ability to achieve goalsAbility to relaxAbility to use dreams and mental tool for problem solvingEliminate procrastinationAbility to reach ideal weightPersonal magnetismStrengthen memory/concentrationBreaking old habitsRelease negative eventsAbility to align body/mind for self healingAbility to take actionIncrease learning abilityBeneficial relationships, prosperityAttitude and skills at workSelf EsteemYouthful vitality
Please select any conditions that apply past or present

CancerHeart DiseaseDiabetesStrokeEpilepsyVaricose VeinsHigh or Low Blood PressureParalysisTMJ DysfunctionArthritisAllergiesSurgeriesGenetic DisordersPhobiasOther
Please list any medications, homeopathic remedies, supplements & reason for taking:
Please list any significant accidents/injuries/traumas to address:
Anything else you'd like to add:
Should be Empty: