Sound Bath Request Form

Fill out the form below to request a sound bath appointment. When an appointment is available, I will contact you via email about scheduling.

Disclaimers:

Though I am a licensed psychologist, sound bath appointments are not therapy sessions, and having a sound bath appointment with me does not make me your therapist. If you are interested in working with me as a psychotherapy patient, please click here.
Sound baths are not medical procedures and do not cure any medical conditions. They are a form of energy healing, utilizing frequencies and sound to aid the body in its own natural healing processes.
Please do not request a sound bath appointment if you fall into any of the following groups:
- People with carotid stenosis or carotid atherosclerosis
- People with cardiac pacemakers, artificial heart valves, or cardiac arrhythmias
- People with a stent or shunt
- People with a deep brain stimulation device (DBS)
- People with epilepsy
- People who are post-surgery, prior to suture removal, prior to full healing and closing of surgical scars
- People who are in the first 12 weeks of pregnancy

Name

First Name

Last Name

Email

Date of Birth

MM

DD

YYYY

Zipcode

for scheduling purposes

Phone

Country

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Country

(###)

###

####

Have you ever experienced a Sound Bath before?

Yes

No

Not sure

Do you have sensitivity to sound or vibration?

Yes

No

I don't know

What do you seek relief from with this sound bath?

A few sentences will suffice!

If you have been in an accident or had surgery in the past 2 years, please provide details below:

Please include nature of accident/injury/surgery and date it occured.

Are you currently pregnant?

Yes

No

How did you hear about this offering?

WAIVER: By submitting this form and typing my name in the box below as my digital signature, I affirm that I understand that sound bath and sound healing are contraindicated for certain medical conditions. I affirm that to the best of my knowledge I am not in any of the at-risk groups listed above, have consulted a medical professional if necessary prior to requesting a sound bath appointment, and that I have completed this form honestly. I understand that I should see a qualified health care provider for any mental or physical ailment of which I am aware. I understand that this sound bath appointment is not a therapy session and does not treat any specific condition. I agree to keep Dr. Alycia Scott updated as to any changes in my medical/physical conditions that might affect my ability to safely experience a sound bath.

Alycia Scott, Psy.D.

Sound Bath Request Form

Disclaimers: