Participant Intake Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PARTICIPANT INTAKE FORM We appreciate you taking the time to review this information, complete the enclosed form, and supply us with the items requested below. Please complete this participant Assessment form before your ceremony/class. If the form is received on the day of our meeting, we may need to review it, which will cut into the class time for everyone! INFORMED CONSENT FORM The United States of America has no licensing policy regarding Sound or Energy Healing, and Raven Runyan is not a licensed Medical Doctor or therapist. I do not deal with drugs, nor do I issue a diagnosis or suggest cures. I aim to provide a safe space for my client to experience healing through natural processes. I consider using sound, energy, herbs, essential oils, crystals, and any other natural healing modality to encourage the body to get back to optimal functioning, and everyone reacts to these methods individually. I make no claims for their medicinal actions nor cite scientific evidence. Any information offered is based on personal experience and traditional uses. My clients agree to make their own choices regarding what they do with the educational material they have been offered and are solely responsible for their own decisions and actions. It is always my recommendation to seek out the advice of a licensed healthcare professional whenever they feel it is necessary regarding their health, especially with serious conditions. Clients need to consult with their physician and get approval to attend healing sessions if they have metal in their bodies, have suffered concussions, have a pacemaker, use an insulin pump, and the like. If in doubt, please consult your physician before our time together. Some issues, such as suicidal thoughts or life-threatening illnesses, are beyond the scope of my expertise, and I would advise you to seek outside help. I understand that: These sessions/workshops/Ceremonies cannot replace treatment by established medical practices but complement them. There are no guarantees as to the results - each person will have their own experience, which will depend on how open you are to receiving when we meet. Raven Runyan is not a licensed physician and will neither diagnose nor prescribe any condition nor make any specific claims regarding the results from the ceremonies received. Nothing in the work Raven does is considered the practice of medicine. I agree to: Raise any questions or concerns about anything I do not understand. I take full responsibility for my health care. Give consent to Raven to conduct a group session to balance my energy system. I acknowledge that this could involve touch, and I can request otherwise. Agree *I agreeBy placing an “x” in the box above and entering your name, you agree to the Cancellation Policy for this session and future sessions. This is required for any and all sessions booked. Please type your Full Name below. This acts as your signature: *General Health AssessmentWe may incorporate sound healing and plant medicines during your class or ceremony. Some of these modalities can interfere with health conditions, allergies, etc. Please complete this assessment to create a class or ceremony experience that will benefit you the most instead of interfering with current health concerns. Name *FirstLastBirth Date *Email *PhoneGeneral HealthWhat are your goals for this ceremony or workshop? *What are your health issues are currently dealing with? *Do you have any specific spiritual practice? *Anything else you think I should know? *Are you pregnant or breast feeding?I am pregnantI am breastfeedingI am neither!Allegies & Plant MedicineHerbs can interfere with current medications as well as different allergies. For example, Chamomile can trigger a reaction for those with a Ragweed allergy. Another example is for people on blood thinners, Rosemary and Goldenseal can increase bleeding issues. For those undergoing HIV treatments, echinacea weakens the immune system's ability to control HIV. This information is needed to keep you safe during our ceremony or class! Do you have allergies? Medication or Herb Allergies? Food Allergies? Allergies? *YesNoMedication or Herb Allergies? *YesNoFood Allergies? *YesNoIf Yes, to What?If Yes, to What? If Yes, to What? Please list any medications you are currently taking: *NOTE: If you checked any boxes above, please contact your physician and get approval for using plants & Herbs in our work! If we cannot use plant medicine, there are other modalities that we can use. My goal is to keep you healthy and safe. Sound Therapy & Health ConditionsPlease check the box next to any of the conditions you may have below. My goal is to tune the therapy to make it safe for you and your body. *I have a pacemaker (H)I have metal screws or plates in my body (R)I am undergoing Chemotherapy for CancerI have Migraines (TE)I have Arrhythmia in my heart (H)I don't have any conditionsI have other health conditions that may be affected by Sound/Vibrational TherapyList any other conditions you may have that may be affected by Sound Therapy: *NOTE: If you checked any boxes above, please contact your physician and get approval for sound therapy before we begin our work! If we cannot use sound therapy, there are other modalities that we can use. My goal is to keep you healthy and safe. Emotional ChecklistPut an X next to each statement that corresponds to the way you often feel. CheckboxesI have Panic Attacks (R)I am restless and unable to relax and have stiff or tense muscles (R)I have Obsessive thoughts or behaviors (S)I am often worried or fearful (SP)I have a Constant fear of rejection (SP)I often feel and anxiety and stress (SP)I am Feeling burned-out (SP)I have Perfectionism or being overly controlling (SP)I have Irritability, Anger and Rage (SP)I have Excessive self-criticism (SP)I have Low self-esteem and poor self-confidence (SP)I have Hyperactivity (SP)I am dealing with grief and loss (H)I have Heightened sensitivity to emotional pain (H)I have Winter blues or seasonal affective disorder (C)I often cry or tear up (T)I have intrusive thoughts and can't release bad memories (TE)I have Lack of focus (TE)I am often moody (TE)I have Negativity (C)Notes you would like to add?Submit