Intake Form – Restoring Harmony Within

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Name *

Age *

Phone (primary) *

Phone (secondary)

Email *

Address *

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City

State

Zip Code

Please tell us who referred you so we can thank them:

What are your goals for our sessions together?

Are there any questions or concerns that you feel we should address prior to your session?

Please mark any of the following that may apply to you:

If you marked any of the above, please provide more information:

Consent *

I have provided my information to the best of my knowledge, including pertinent health information.

Signature of Client *

Clear Signature

(or Parent/Guardian if client is under 18)

Date: *

Permission To Use Data: By signing below, you give permission to share your case in a database exclusive to Certified Biofield Tuning practitioners for educational and research purposes. (For example: if Biofield Tuning successfully resolved your ailment, the practitioner’s process and protocol, as well as the outcome of the treatment would be shared with other practitioners for their reference). Your identity and personal information will remain anonymous and confidential at all times.

Signature of Client *

Clear Signature

(or Parent/Guardian if client is under 18)

Date: *

Biofield Tuning Disclaimer

Biofield Tuning and its associated processes should not be relied upon as health, medical, psychological, or other professional advice of any kind or nature. Biofield Tuning is an energy medicine* method developed by Eileen McKusick, an author, researcher and practitioner, (www.biofieldtuning.com) for self-healing and wellness that uses sound waves produced by specialized tuning forks in the biofield that surrounds the human body. Energy medicine methods, such as Biofield Tuning, are designed to assess where the body’s energies are blocked, trapped, or not in harmony and then correct the flow of these energies by aligning the body’s energies to boost health and vitality. The theory of energy medicine methods is that the flow and balance of the body’s electromagnetic and subtle energies are important for physical, spiritual, and emotional health, and for fostering overall well-being. You understand and accept that when utilizing Biofield Tuning the practitioner is not “diagnosing” or “treating” the physical body, which is the domain of the medical field and other allied healthcare professionals, but instead is connecting to the energy or subtle “bodies” of the client that make it possible to manifest a change or transformation, which is then experienced directly by the client. You understand there is a distinction between “healing” using Biofield Tuning and the practice of medicine or any other licensed health care practice. Although Biofield Tuning appears to have promising emotional, spiritual, and physical health benefits, it has yet to be fully researched by the Western academic, medical, and psychological communities. Therefore, Biofield Tuning may be considered experimental and the extent of its effectiveness, as well as its risks and benefits, are not fully known. Energy medicine methods such as Biofield Tuning are considered “alternative” or “complementary” to the healing arts licensed in the United States. Further, energy medicine methods such as Biofield Tuning are self-regulated and the State of _________________ (if applicable) does not license, certify, or register Biofield Tuning practitioners.

Signature of Client *

Clear Signature

(or Parent/Guardian if client is under 18)

Date: *

*Energy medicine is a collective term used that refers to a variety of energy techniques, processes, and methods based on the use, modification, and manipulation of energy fields that look at imbalances within an individual’s energy system as well as the energetic influence of thoughts, beliefs, and emotions on the body.

After a Biofield Tuning Session

Everyone is different and will have a unique experience to a Biofield Tuning treatment. Most people who receive Biofield Tuning sessions report feeling clearer, calmer, more relaxed, and more self-aware. Sometimes clients will experience a detox, which can vary greatly. Some clients have reported:

Profound exhaustion and tiredness, needing to sleep or lay low for a day or more: generally, happens with people who have been ‘running on empty’.
Extreme emotionalism, or being very aware of formerly masked or buried emotions- crying a lot, or being very angry.
Headaches and/or dizziness
In very rare instances: skin rashes, mucus, fevers, vomiting, loose stools, excessive thirst

Generally, these symptoms are detoxification and pass within a day or two, but if a condition persists, it is important to see your practitioner again - sooner than later. Sometimes people can get ‘stuck’ in the unwinding process and need an additional boost to complete the adjustments.

If you have any questions or concerns at all, please feel free to discuss these with your Biofield Tuning practitioner.

Post Session Care

Hydrotherapy:

Hydrotherapy, in and out, is optimum after a sound therapy session. Drinking plenty of water and herbal teas after a session is recommended, and soaking in a mineral or epsom salt bath for 20 minutes minimum supports the body in detoxifying or releasing any physical components from the blockages released from the energy field. It is also beneficial to be well hydrated before a session due to the sound-conductive properties of water.

Grounding:

In climates that permit, it is highly recommended to spend some time walking barefoot outside in the grass or soil after your session. Connecting the bare feet to the earth will help to ground your energy, drawing excess energy down and out of the body, and drawing the earth’s negatively charged ions up into the body. This helps create a state of electromagnetic equilibrium in the system that can potentially relieve a wide variety of discomforts.

Homework:

Becoming more well-balanced usually requires a change in perception and/or action of some kind or another. Simply becoming more aware of our habitual subconscious behaviors, becoming aware of ourselves from the place of ‘the witness,’ broadens the trajectory of our life possibilities.

Hence, we become more free to choose healthy and self-supporting behaviors.

Biofield Tuning Disclaimer

After a Biofield Tuning Session

Post Session Care

Hydrotherapy:

Grounding:

Homework:

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