Client Details

Name *

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Date of Birth

YYYY

Gender

Male

Female

I'm not defined by gender labels

Email Address *

Emergency Contact

Relationship

Emergency Contact Phone

(###)

###

####

How did you hear about us?

What areas of your life do you hope floating will help improve?

Physical Goals

Increased Energy

Alleviate Physical Pain

Athletic Enhancement

Rapid Physical Recovery

Headache Relief

Lower Blood Pressure

Improve Sleep Quality

Speed Jet Leg

Mental Goals

Increase Motivation

Improve Concentration

Improve Problem-Solving

Increase Creativity

Increase Intuition

Meditation Practice

Personal Growth

Elevate Mood

Clinical Goals

Stress Relief

Reduce Stress-Related Illness

Depression Relief

Anxiety Relief

PTSD Symptoms

Fibromyalgia Relief

Eliminate Addictive Behaviors

Eating Disorder

Any additional goals not listed above?

If experiencing physical pain, where is the pain?

List anything that has not worked to relieve physical pain:

Are you currently taking any medications, supplements, or vitamins?

Yes

If yes, what and how often?

Please list any additional medical conditions:

Do you have any concerns while floating?