StillPoint Center

Sound-Energy Balancing

Client Intake Questionnaire

Please Print Clearly
 

_____/_____/_____      (_______)_______________

Date                                 Phone

_____________________________________      _____________________

Name                                                                      Email Address
 

________________________________________________________________

Address City State Zip

Gender: M or F     Birth Date _____/_____/_____

Exact birth time (optional but important) __________

___________________________________            __________________________

Your Occupation                                                      Emergency Contact / Phone #
 

How did you hear about us?

Website ___  Brochure___ Sign___ Ad________ Other___________

Referred (please name)____________________________________

Please complete the following questions:
 
What physical activities do you engage in on a regular basis?
______________________________________________________________________
How often:___________________   Length of Time:_______________________

Are any movements or activities limited?
_______________________________________________________________________
 
Please describe your work/school and home life (1=least, 5=most)

Level of stress at work/school (please circle):     1 2 3 4 5
Level of work/school satisfaction:                          1 2 3 4 5
Level of stress in primary relationship:                  1 2 3 4 5
Level of satisfaction in primary relationship:        1 2 3 4 5
Level of stress at home:                                           1 2 3 4 5
Level of satisfaction with home life:                       1 2 3 4 5

Are you experiencing stress in any other relationship or situation?
_________________________________________________________________________
_________________________________________________________________________
 

Do you have any specific spiritual practices? Please describe:
______________________________________________________________________
_______________________________________________________________________
 

What other treatments are you receiving? (i.e.: acupuncture, chiropractic….)
___________________________________________________________________________
 

What do you want to achieve or change in terms of your health, wellness, and spiritual growth? ____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
 

Practitioner Comments:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
 

Provisions of the Practitioner and Client’s Waiver
Alternative healing techniques are not a substitute for medical examination and diagnosis. I understand that alternative healing techniques should not be construed as a substitute for medical examination, diagnosis, and treatment. It is recommended that I see a physician for any physical ailment that I may have. I accept responsibility of payment for services provided.
 
 
 
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Signature and Date