Client Intake Form — Of Sound Body and Mind

Personal Information

First Name*

Last Name*

Email Address*

Phone Number*

Date of Birth*

Home Address*

Emergency Contact

Full Name*

Relationship*

Phone Number*

Health History

This information helps Kirsti tailor your session safely. All health information is kept strictly confidential.

Current Medical Conditions or Diagnoses

Current Medications

I have received sound healing or energy healing sessions before

Your Session

Reason for Visit / Intentions for Your Session

How did you hear about Of Sound Body and Mind?

Consent & Acknowledgments

Informed Consent & Liability Waiver

I understand that sound healing, Reiki, and harp therapy are complementary wellness practices and are not a substitute for medical diagnosis, treatment, or advice from a licensed healthcare provider. I acknowledge that Kirsti Kaldro is not a licensed medical professional and that sessions at Of Sound Body and Mind are intended to support relaxation and general well-being.

I voluntarily choose to receive these services and release Of Sound Body and Mind, its practitioners, and its affiliates from any liability for injury, illness, or adverse effects that may arise from participation in sessions, except in cases of gross negligence.

I confirm that the health information I have provided above is accurate and complete to the best of my knowledge, and I agree to inform my practitioner of any changes to my health status.

I have read and agree to the Informed Consent & Liability Waiver above.*

I have read and acknowledge the Notice of Privacy Practices.*

Signature — Type your full legal name to sign*

By typing your name above you are providing your electronic signature.