Biofield Tuning Intake Forms

Biofield Therapy Intake
Name *

First Name Last Name
Age *
Phone Number (Primary) *
Please enter a valid phone number.
Phone Number (Secondary)
Please enter a valid phone number.
Email *
example@example.com
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / 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:

Pregnancy or planning to become pregnant Cancer or terminal illness Obesity Heart condition/pacemaker Concussion or head injury in the last 6 months Recent broken bones Currently taking medications Other
If you marked any of the above, please provide more information:
I have provided my information to the best of my knowledge, including patient health information.
Signature of Client (Or Parent/Guardian if client is under 18): *

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Date *

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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 our practitioners for their reference). Your identity and personal information will remain anonymous and confidential at all times.
Signature of Client (or Parent/Guardian if the client is under 18): *

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Date *

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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

blanks* (if applicable) does not license, certify, or register Biofield Tuning practitioners.
Signature of Client (or Parent/Guardian if client is under 18): *

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Date *

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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.

CLIENT AGREEMENT

Please read and sign where applicable
I, First Name* Last Name* , give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.

I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk. To mitigate the risk, I agree to wear a face covering at all times during my session.

I also understand:

1.That massage therapy and/or acupuncture
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.
2.That the massage therapists and/or acupuncturists
- do not diagnose illness, disease or any other physical or mental disorder
- do not prescribe medical treatment or pharmaceuticals
- do not perform any spinal manipulations
3.Cancellation

I acknowledge that any and all of my appointment times are reserved exclusively for me and that I am responsible to remember them. Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients. We hope this will alleviate any stress and hesitation you have about an upcoming appointment. If you need to reschedule for whatever reason, and especially if you are not feeling well, we understand and request for you to please contact us as soon as possible to reschedule. To further support you, there will be no penalties for cancellations at this time.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
Name *

First Name Last Name
Signature *

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Date *

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Date

POLICIES

Welcome! And thank you for choosing The Teal Center! Please read and initial each of the following:
* Appointments missed, cancelled or rescheduled with less than 24 hours notice will be charged in full. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are made 48 hours prior to the scheduled appointment.
* The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to the Teal Center.
* If you have a cold or other contagious illness, please call us before your so we can check with your therapist to see if it is appropriate for you to come in.
blanks* In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.
blanks* Tips are appreciated but never expected. If you wish to leave a gratuity for therapist we ask that you do so in cash or by check made directly to the therapist.
blanks* If you move or change numbers, it is your responsibility to inform us. This is important information so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.
blanks* The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.
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Biofield Therapy Intake

Biofield Tuning Disclaimer

CLIENT AGREEMENT

POLICIES