case study form | riverleaf

Date when you fill in the form

Day

Month

Year

First name

Last name

Email

Phone

Next of Kin Contact: Name + phone

How did you know about this case study?

Why are you coming for sound therapy? What would you like to work on?

Are you participating for Chronic pain research?

Y

N

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?

April 2025

May 2025

June 2025

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.

Would you like to join my riverleaf newsletter?

Y

N

Do you have any question?

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 ZOOM call.

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 ZOOM call.