Follow the Sound mandatory health screening form

We are so excited you want to join our sound meditation in
Kalispell, MT, Saturday, April 6th and Sunday, April 7th
*Choose a day that works for you!

To reserve your space, please fill out this form and make your payment below.

This intake form has been created to provide us with initial mandatory information for potential participants who have shown interest in our meditations and to update the health/medication status of previous and current participants. This information is completely confidential and is NEVER shared with anyone beyond the facilitators of our events.

***Please download and read the Informed Consent for Ketamine Therapy form. You will be asked to type your name to serve as an acknowledgment that you have read the consent in its entirety and agree to the term when you complete the intake form.

Informed Consent for Ketamine Therapy

We would never want to turn you away because of financial hurdles. If you need a payment plan or need to explore another arrangement, please fill out this form and then email info@followthesound.co with more details.

Name

First Name

Last Name

Phone

(###)

###

####

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Sound Meditation Date

Please let us know which day you plan to attend.

YYYY

How did you hear about us?

Have you experienced this type of sound meditation before?

Have you ever attended a Follow the Sound event before?

If yes, who was the facilitator?

*A medical prescription is required to participate in this event, which you will be receiving from Alpine Health. Typing your first and last name below serves as your signature and acknowledgment of the need for a prescription as well as confirmation that you have read the consent provided for download above, in its entirety and agree to the terms.

I understand that I will not be able to drive for 24 hours following the administration of Ketamine and I will arrange to have a driver transport me after the event.

I AGREE AND UNDERSTAND

It is required that you disclose any personal or family history of schizophrenia. This information will only be shared with the facilitators

If yes, please explain.

It is required that you disclose any history of PTSD, drug or alcohol abuse, anxiety, or depression, etc. This information will only be shared with the facilitators.

Please list any allergies you have here:

I understand that I must share my history of taking antidepressant medication (SSRIs, MAO inhibitors) or anti-hypertensives (high blood pressure medication). This information will only be shared with the facilitators.

Please list any medical issues or concerns you have as well as family history of mental illness. This information will only be shared with the facilitators.

I understand that once I have registered for the event, my deposit is non-refundable. If I need to cancel for any reason I will be given a credit to a future event, and I understand that I am responsible for my own schedule.

Yes, I understand

To maintain the safety of this work and in respect for all participants of the meditation, I agree to hold the details of this work confidential. I will not share with anyone the identity of those who are participating in the meditation. This includes maintaining confidentiality for all facilitators, organizers, helpers and healers who are also participating in the ceremony.

Yes

I understand that the facilitators reserve the right to deny my participation if they deem that it would be unsafe for me, for others, or for any other important reason that they deem appropriate. I understand that if this should happen before the start of the sound meditation we will refund the money completely.

Yes

I understand that the publication of texts, photo’s, sound recordings, videos are prohibited. No recordings or photographs can be made without permission of the organizers. No publications, interviews or details of any participant or locations may be given to any non-member, journalist or legal authority, without the permission of the organizers.

Yes

Feel free to share your intentions for the ceremony.

NAME: (typing your full name here serves as your signature)

Todays Date

YYYY