Sound & Meditation Client Intake Form

THE NIMBLE ALCHEMIST LLC
Sound & Meditation
SOUND HEALING/GUIDED MEDITATION CLIENT INTAKE WAIVER FORM
Name: First and Last
Date of Birth MM/DD/YYYY

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Date
Phone Number
By entering your phone number, you agree to receive informational messages (appointment reminders, event announcements, account notifications, etc.) from The Nimble Alchemist LLC. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at gabrielle@thenimblealchemist.com. You can opt out at any time by replying STOP.Format: (000) 000-0000.
Email
example@example.com
Home Address
How did you hear about us?
I.e, Owner, Word of Mouth, Fair, Friend, Family, etc.
Have you done any of the following practices before? (If yes, please check any and all that apply)
If "Yes" was checked, when was your last session?
A rough estimate of the previous session is okay!
Number of previous sessions?
A rough estimate of the number of sessions is okay here too!
Do you have any goals or particular concerns for your session?
This will help set the intention for the session. We will come back to this on the day of, so no worries if you need time to think through intentions or even reset them!
I understand and acknowledge that the guided meditation and sound healing services are holistic practices aimed to support relaxation, stress relief, and personal well-being, and are not intended to diagnose, treat, or cure any medical or psychological conditions. I understand that the practitioner, Gabrielle Hodges of The Nimble Alchemist LLC, is not a licensed medical professional, and these services are not a substitute for medical care, psychotherapy, or other professional advice from licensed providers. I am voluntarily participating in the session and acknowledge that I am solely responsible for my own physical, emotional, spiritual and mental well-being, decisions, and choices arising out of or as a result of the session. I acknowledge that the practitioner is not liable for any outcomes resulting from my participation.

I understand that the services may involve the use of instruments near or around the body, and I consent to this practice unless I indicate otherwise. I agree to communicate any discomfort or need for adjustment at any time during the session. I understand that these services may evoke emotional responses or altered states of awareness, and I accept full responsibility for how I choose to engage with and respond to them. I understand that all personal information shared during sessions will be kept confidential unless disclosure is required by law. I release, waive and hold harmless Gabrielle Hodges and The Nimble Alchemist LLC from any and all liability, claims, or damages that may arise from or related to my participation in these services.

By signing below, I acknowledge that I have read, understood and voluntarily agree to abide by the terms of this waiver.
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THE NIMBLE ALCHEMIST LLC

Sound & Meditation

SOUND HEALING/GUIDED MEDITATION CLIENT INTAKE WAIVER FORM