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Thanks for your interest in joining the
1:2:1
SOUND THERAPY
CASE STUDY
please fill out this form, and I will contact you soon for an intake
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call.
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Date when you fill in the form
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Month
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First name
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Last name
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Email
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Phone
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Next of Kin Contact: Name + phone
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How did you know about this case study?
Why are you coming for sound therapy? What would you like to work on?
*
Are you less than 3 months pregnant?
*
Y
N
N/A
Do you have any metal implants, plates or other metallic items (other than tooth fillings) in your body?
*
Y
N
If so, where? any complications/pain
Do you have seizures of any kind?
*
Y
N
Are they Grand Mal (now known as ‘Tonic-clonic’)
Y
N
To your knowledge, have your seizures ever been triggered by sound?
Y
N
If so, please give details
Do you knowingly have any other condition that is triggered by sound – please give details
*
Do you have a severe physical or mental health condition?
*
Y
N
Do you have mild to moderate mental or physical health condition?
*
Y
N
How do you manage your symptoms?
How frequently do you experience them?
How severely do you experience it on a scale of 1 being hardly detectable to 6 – severely debilitating?
Are there any known triggers?
If you join the case study, which months will you be available?
*
May 2025
June 2025
if you join the case study, which time slot are you available?
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Monday afternoon
Tuesday evening
Wednesday afternoon
Wednesday evening
Thursday afternoon
Thursday evening
Can you give 3 dates & moments in the coming week for an intake call? Once you receive the email with intake call, please also confirm it.
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Do you have any question?
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