Luminous Soul Center Healing Session Registration & Intake Form

Full Name*

First NameLast Name

Email Address*

example@example.com

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Phone Number*

Please enter a valid phone number.

Birthdate*

MonthDayYear

Emergency Contact Name

Emergency Contact Phone Number

Please enter a valid phone number.

How did you hear about these healing sessions?

Have you participated in energy or sound healing sessions before?*

YesNo

What is your experience with energy or sound healing?

Are you experiencing pain or suffering, physically, emotionally, mentally or spiritually?*

YesNo

If yes, please describe.

Please rate the intensity of your pain or suffering on a scale from 1 to 10, 10 being the most intense and 1 being the least intense.

Are you interested in going to the core of your pain or life issues, facing them, releasing them, learning from them and understanding the root cause or karmic pattern?*

YesNo

What are your intentions for your healing session?*

Please select any that apply:

Please select any that apply: High stress, Anxiety, Depression, Sleep issues, Prefer not to answer

Please select any that apply: Currently taking prescription medication, Alcohol use, Recreational drug use

Please select any that apply: Pregnant, Postpartum, None apply

Please select any that apply: Sound, Touch, Light, Fragrance, Dizziness

Consent: I understand this session is not medical treatment and will communicate any discomfort during the session.*

Thank you for scheduling your appointment. By scheduling, you acknowledge and agree to the payment and cancellation policy, as well as the session disclaimer outlined below.

PAYMENT: All sessions are prepaid for the estimated duration selected at booking. If a session extends beyond the scheduled time, you will be responsible for the additional time only if you confirm that you would like to continue. Any remaining balance will be due at the end of the session. *Deposits for group sessions may be applied if arrangements are made in advance.

CANCELLATION: Sessions are refundable if canceled at least 24 hours prior to the scheduled appointment time. Cancellations made less than 24 hours before the appointment are non-refundable.

DISCLAIMER: All guidance, movement, healing, sound, or intuitive services are provided for informational and educational purposes only and are not intended to diagnose, treat, cure, or prevent any medical or psychological condition. These sessions do not replace medical advice, diagnosis, or treatment from a licensed healthcare provider. You understand and agree that it is your responsibility to consult with your primary healthcare provider or any other qualified medical professional regarding any information received during a session. By receiving services from the practitioners, Jaya Sarada or Arielle Beauduy, you release these practitioners and The Luminous Soul Center for Well Being from any and all liability related to your participation in movement or healing sessions. You acknowledge that you assume full responsibility for your own health, well-being, and any outcomes resulting from these sessions. By signing below, you confirm that you provided truthful and accurate responses to the questions in this intake form and have read, understand, and agree to the payment, cancellation policy and the session disclaimer as outlined above.

Signature*

Date*

Date

Luminous Soul Center Healing Session Registration & Intake Form

Medical Considerations

Mental & Emotional Well-Being

Medications & Substances

Pregnancy

Sensitivities

Appointment Confirmation, Payment & Session Agreement