Name

Pronouns

Phone

DOB

Current Living Situation? (optional)

What inspired you to make this appointment?

What, if any, are your goals?

Current or past religious and spiritual practices:

I currently deal with stress by:

Medical Conditions:

Other significant information for Tara to know:

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Waiver and Release of Liability

Although Tara O holds a clinical mental health license, Soul Support sessions and sound healing are not intended to replace therapy or medical services. I accept and acknowledge that the services provided to me by Peaceful Stillness LLC and Tara O are alternative modalities, not clinical mental health services, and nothing about my relationship with Peaceful Stillness LLC and Tara O shall create a patient/provider relationship. If I am in a crisis or emergency, I agree to call 911 or report to an emergency room or facility that provides emergency mental health services.

The United States of America currently has no licensing policy in regard to Sound Healing, and Tara O is not a licensed Medical Doctor. Tara O does not deal with substances, nor issue a diagnosis or suggest cures. Her purpose is to provide a safe space for clients to experience healing. The use of sound is considered a way to encourage the body to get back to optimal functioning. Everyone reacts to these methods individually. No claims are made for their medicinal actions, nor is scientific evidence cited. Any information offered is done so on the basis of personal experience and traditional uses.

Potential risks associated with Soul Support sessions include but are not limited to emotional distress due to the processing of events and the client’s perception of the nature of life. I agree to disclose any and all medical issues to Tara O. Clients need to consult with their physician and get approval to attend sound healing sessions if they have metal in their bodies, suffered concussions, have a pacemaker, use an insulin pump, and the like. If in doubt, consult your physician before our time together. Potential risks of sound healing may include different results such as heat or cold, shivers, nausea, headache, or emotional responses.

Notwithstanding the risk stated above, I acknowledge I am voluntarily participating in Soul Support sessions and or sound healing with knowledge of the risks involved. The undersigned hereby assumes all risk of injury or harm as a result of the activities specified above and agrees to release, indemnify, defend, and forever discharge Peaceful Stillness LLC from all liability, claims, demands, damages, costs, expenses, and causes of action due to death, injury, loss, or damage to the undersigned.

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