Customer Intake Form
Personal RDR Sound

Cost: $150

(All sales are final and there is a no-return policy)

 

The following questions on this intake form is the foundation that allows us to design your personalized RDR Sound. Please thoroughly complete the form to the best of your ability.
Contact Information
Name:
Address:
Email:

Occupation:
Where did you hear about us:
What medication(s) are you currently taking?:
What is your biggest fear?:
What is your biggest dream?:
What is your biggest goal for using the RDR sounds?:
Do you want to have a conversation about your intake form? (Note: This conversation is included and will not incur additional charges.)

YesNo

Please review the list and check items that concern you:








































On a scale of 0-4 (0 = non or not applicable, 1= a little, 2 = moderate, 3 = a lot 4 = extreme) rate how much you have experienced each symptom over the past weeks.
Symptoms
Feeling sad, down or depressed
Avoiding certain people or places
Loss of interest in activities I normally enjoy
Low energy / feeling tired
Sleep problems
Eating too much or too little
Not able to think clearly
Feeling no pleasure in life
Anxiety attacks
Worrying about things
Angry outburts
Low self-esteem
Low self-confidence
Feeling guilty
Feeling too stressed
Drinking too much
Abusing drugs
Abusing prescribed medication
Not getting my work done
Feeling unhappy with my workplace
Cannot relax
Forgetting things
Experience trauma
Nightmares
Scale
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
1234
Symptoms
Feeling sad, down or depressed
1234
Avoiding certain people or places
1234
Loss of interest in activities I normally enjoy
1234
Low energy / feeling tired
1234
Sleep problems
1234
Eating too much or too little
1234
Not able to think clearly
1234
Feeling no pleasure in life
1234
Anxiety attacks
1234
Worrying about things
1234
Angry outburts
1234
Low self-esteem
1234
Low self-confidence
1234
Feeling guilty
1234
Feeling too stressed
1234
Drinking too much
1234
Abusing drugs
1234
Abusing prescribed medication
1234
Not getting my work done
1234
Feeling unhappy with my workplace
1234
Cannot relax
1234
Forgetting things
1234
Experience trauma
1234
Nightmares
1234
Please explain if there is anything that is not listed, but is relevant in this session:
By checking on the I acknowledge checkbox you acknowledge that you do not have epilepsy. By checking on the I acknowledge checkbox you also acknowledge that the sound is not a medical device, and is not FDA approved. Using this sound is under your own discretion.


Disclaimer

Wholesome Health Lounge, Reset, Delete, and Re-Progammation™ and any of its products do not diagnose, cure, prevent or treat diseases. If you have a medical condition or concern, please consult an appropriate health care professional. The Therapeutic Sound Room information and offerings have not been evaluated by any government agency or regulatory organization – including the FDA. Treatments provide relaxation and stress relief, which has been shown to be a contributor to most issues emotionally and physically.

The content available is for general information and interest only and we do not warrant or guarantee its accuracy or completeness. It is your responsibility to judge the accuracy or completeness of the content before relying on it in any way. Your use of the content (for whatever purpose) is at your own risk, enjoyment and improved quality of life.

Any personal information acquired was voluntarily provided by the information owner. (NOTE: Anyone under 18 years old must be accompanied by a legal guardian or parent.)