CLIENT INTAKE FORM

JC Nirvana Holistic Practices

Sound & Frequency Healing | Biofield Tuning | Meditation Support (LoMeCu) | Intuitive Energy Work

Please complete the following information prior to your first session. This helps us understand your needs and ensure a safe, supportive experience.

Full Name *

Date of birth

Address

Street Address

City

State

Country

Postal code

Email *

Phone *

HEALTH & WELLBEING

Please indicate any of the following that apply:

Pregnancy or trying to conceive

Pacemaker or implanted electrical device

Cancer (current diagnosis or undergoing treatment)

Heart condition (e.g., angina, arrhythmia, heart failure)

Epilepsy or history of seizures

Recent concussion or head injury (within 6 months)

Recent surgery or broken/fractured bones (within 3 months)

Morbid obesity (BMI of 40 or above)

Metal implants (e.g., surgical rods, plates, dental implants)

Diagnosed mental health condition (e.g., PTSD, anxiety, bipolar disorder, schizophrenia)

Currently taking prescribed medication (please list below)

Allergies to wool, buckwheat, or other natural materials (LoMeCu users)

If you ticked any of the above, please provide details:

Current medications and dosages (if applicable):

SESSION GOALS

Please share any intentions or focus areas for our session today and your broader wellbeing goals:

CONSENT & ACKNOWLEDGEMENT

I understand that JC Nirvana's services are complementary wellness practices and are not a substitute for medical or psychological diagnosis or treatment. I agree to take full responsibility for my health and wellbeing, and I have disclosed all relevant health information to the best of my knowledge.

I consent to the use of light touch and/or the application of weighted tuning forks on the body where appropriate. I understand I may withdraw this consent at any time during the session.

Signature *

Clear

Date *

(If under 18, parent/guardian signature required)

Parent/Guardian Signature

Clear

Date

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to for assistance. You can reply STOP to unsubscribe at any time.

I confirm that I read the term & condition.