Primordial Sound Mediation Course Intake Form

First Name *

Last Name *

Email *

Phone Number *

Street Address *

City *

State *

Zip Code *

Gender *

Occupation *

Birth Details

Date of birth

City *

State *

Have you ever been instructed in a mantra meditation technique? *

Date instructed

Do you still practice it?

How is your health?

Mental: *

Physical: *

Medications

Emergency Contact:

First Name *

Phone Number *

Last Name *

My decision to learn Primordial Sound Meditation (PSM) is a personal decision. I have not been made any promises or warranties that I will receive any benefits or specific results. I understand the PSM is not a substitute for treatment or services ordinarily provided by health care professionals for physiological or psychological conditions. I further understand that any instruction given to me during the PSM is for me personally and may not be appropriate for others. In consideration for teaching the PSM, I hereby agree to hold Anne Vetter, Doorways To Your Soul, and their officers, agents, and employees harmless in any claims brought by me, or on my behalf, which contradict the above.

I agree with the statement above

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