Shine Zen Studio Client Intake & Consent Form
Please complete this form to help us create a supportive experience for your session.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health History
Please check any that currently apply to you:
Pregnancy
Pacemaker or implanted medical device
History of seizures or epilepsy
Recent surgery (within the last 6 months)
Active cancer treatment
Severe anxiety or PTSD
Chronic pain condition
None of the above
Are you currently taking any medications? If yes, please list them.
Is there anything else about your physical or emotional health you'd like me to know before your session?
Session Intention
What are you hoping to experience or release in today's session?
Have you ever experienced sound healing or Reiki before?
Yes
No
Not sure — I'm curious though!
Consent and Waiver
Consent and Waiver
I understand that sound healing and Reiki are complementary wellness practices and are not a substitute for medical treatment, diagnosis, or advice. I affirm that I have disclosed all relevant health conditions to the best of my knowledge. I agree to communicate openly with Andrea before and during my session and understand that I may stop or modify the session at any time. By signing below, I consent to receive services at Shine Zen Studio and release Andrea and Shine Zen Studio from liability for any adverse reactions resulting from undisclosed health conditions.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: