Name
*
First Name
Last Name
Phone
*
(###)
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####
Emergency Contact Phone Number
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Services
*
Please select the service(s) booked.
Date of Birth
*
MM
DD
YYYY
Time of birth if known
Hour
Minute
Second
AM
PM
Height
*
Occupation
What is your intention or focus for your upcoming session/s?
*
What are your expectations going into this experience?
*
Wellness Services Experience
Please select any experiences you have had involving wellness.
Rate your level of stress ( 1= lowest, 5 = highest)
What is the main source of stress.
*
Select all statements that you agree with.
What is your most volatile emotion? *
*
I cannot feel the following emotions often/well: *
*
I feel the following emotions frequently: *
*
Which element/s do you connect with most? *
*
Please select
If you selected aromatherapy as a complementary service please fill out this section.
*
Do you have any favorite scent groups or scents that bring you into a state of calm? Please check all that apply.
Do you have any essential oil or scent sensitivities?
Are you allergic to palo santo or sage?
*
Medical Information (Please check all that apply)
Please list any medical information not listed above.
*
Please list any accidents or surgeries in the last 2 years.
*
Do you have any sensitivity to sound or vibration?
*
Do you have any difficulty lying on your back?
*
We strive to make our space a comfortable temperature to suit your needs. How would you characterize your resting body temperature?
*
How did you hear about us?
*
For every referral that results in a session booking, you will receive 10% off your next session. If someone referred you to seek an appointment today, please let us know who so they may receive their discount.
*
Confidentiality & Liability Agreement
*
No information about any client will be discussed or shared with any third party without the written consent of the client or parent/guardian if the client is under 18.
Liability Waiver Agreement
*
By writing my name below, I hereby agree to the following: I am participating in a sound ceremony or crystal healing during which I will receive information and instruction about meditation, sound healing and crystal healing. I understand that at some points, the sound can be quite loud. I recognize that I may also choose to do a physical movement, such as sitting, laying down, and light stretching during the session. I understand that it is my responsibility to consult with a physician before and regarding my participation in Blackberry Moon services. I represent and warrant that I have no physical, mental, or psychological health condition that would prevent my safe participation in any Blackberry Moon service. I agree to assume full responsibility for any risks, injuries or damages, known and unknown, which I might incur as a result of participating in a Blackberry Moon service. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Blackberry Moon, Darcy Dolge, volunteers, and agents. I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my typed or written name serves as the complete and unconditional release of all liability to the greatest extent allowed by law in the State of Oregon. By writing your email above, you are opting in to our email list where we will send you updates for our latest events, album releases, and other offerings. You can unsubscribe from our emails at any time through the link at the bottom of every email.
