Client Forms - Dallas/Fort Worth Acutonics

Date(Required)

Name(Required)

First Last

Address(Required)

Street Address Apt or Suite # City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Enter Email Confirm Email

Date of birth(Required)

Occupation(Required)

Emergency Contact(Required)

Name and phone

Emergency Contact Relationship(Required)

Contact's relationship to you

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Are you currently under medical supervision?(Required)

YES

NO

If Yes to medical supervision, please explain

Are you currently taking any medications or herbs?(Required)

YES

NO

List any medications or herbs you currently take:

Column 1

Column 2

Column 3

You may add more rows to list more

How is your physical health?(Required)

How is your energy level?

What time of day do you have high energy?(Required)

What time of day is your low energy?(Required)

How is your digestion? Check all that apply(Required)

Gas

Bloating

Food Allergies

Other

None- good digestion

When do you have gas/bloating or food allergies?

How is your urination? Check all that apply:(Required)

Incontinence

Frequent Urination

Urgency to urinate

UTI's (Urinary tract infections)

Night time frequency

No urinary imbalances

Explain any checked urinary imbalances

Check all that apply to your stools or how often you move your bowels:(Required)

Constipation

Diarrhea

Regular/Normal

(how often you move bowels))

Please explain checked bowel imbalances

Sleeping Patterns:(Required)

No problems with sleep

Insomnia

Trouble going to sleep

Wake up during night

Inability to go back to sleep if wake up during night

Other

If you wake up during night or cannot get to sleep until later, what time is this usually?(Required)

:

Acutonics Consent to Treat(Required)

I consent to Acutonics treatment by Mary Burke-Kelly. I will discuss a sesson plan with her and have the opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and any future conditions for which I seek treatment.

Acutonics is a non-invasive methodology that draws on Chinese Medicine and incorporates the use of sound vibration. In an Acutonics session specific vibratory energy is created through precision-calibrated tuning forks, hand chimes, and planetary gongs. The frequencies generated by the Acutonics sound tools are scientifically derived from the orbital properties of the heavenly bodies, which give us musical intervals, archetypes and correspondences that allow the practitioner to fine tune the therapeutic frequencies that are applied to acupuncture points, chakras, and points of pain. The Acutonics Institute of Integrative Medicine created this modality, and I have studied with the institute and incorporate it into my clinical practice. The institute believes in the creation of partnerships between practitioner and client and in finding the right balance between conventional and alternative health care models that facilitate the body’s innate wisdom to heal. During your session specific tuning forks, and other sound-based tools may be selected based on the information that you provided during intake. A treatment plan will be reviewed with you prior to the session. It is important for you to understand that Acutonics does not diagnosis, treat, or cure specific medical conditions. The methodology is complementary, therapeutic, and integrative. It promotes wellness, balance, and wellbeing.
By signing below, I acknowledge the following:
• I have honestly and comprehensively answered the questions asked on the intake form.
• I have stated any relevant medical conditions and will keep my practitioner updated on my health should anything change.
• It is my responsibility to notify my practitioner if any information provided changes.
• If at any time during the session I feel uncomfortable I will inform my practitioner immediately.
• I recognize and understand my responsibilities as a client.
• I fully understand the information presented and voluntarily consent to treatment.
• I fully understand that there is no guarantee or implied guarantee about the success of the treatments given.
• I have read and understand the above description of Acutonics.
• I understand the scope of practice of an Acutonics practitioner.

Dallas/Fort Worth needs permission to contact you regarding your appointments or appointment changes. Which methods do you prefer?(Required)

Text message

Email

Phone call

If you scheduled your appointment via the Calendly link, you will receive reminders automatically to the text or email you provided to that app.

Name

This field is for validation purposes and should be left unchanged.

DFWA NEW CLIENT FORMS

Dallas/ Fort Worth Acutonics New Client Intake Form

New Client Input Form

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