New Cilent Form
Welcome! Please take time to Fill out this form as soon as possible. I am ready for us to connect and plan the next best steps together. JessBeU supports individuals who are committed to creating a consistent routine to manage their well-being. Each participant is informed of a consent and waiver of liability. If you are interested in my services, please answer this entire form. If your application is approved, you will be contacted by email.

I acknowledge that I am voluntarily participating in the JessBeu,llc wellness Services.

I acknowledge and understand that I am responsible for all aspects of my health and well-being. I further recognize and understand that the instructions and advice presented to me during the coaching sessions are in no way intended as substitutes for medical and/or other professional counseling. If I have any health concerns that may interfere with my participation in the coaching sessions. I understand that I should consult my healthcare provider before beginning 1:1 coaching or wellness workshops. If I experience pain or difficulty that is causing for concern during or after practicing any exercise, I understand that I should stop immediately and consult my healthcare provider before continuing on with the sessions.

I recognize, understand, and assume all risks associated with my voluntary participation in the coaching, including, but not limited to, those risks that may result in personal injury and including death. In giving my informed consent to participate in services, I hereby release JessBeU, LLC  from any and all claims, now or in the future, that I may have as a result of my voluntary participation in the services.  

Sign in to Google to save your progress. Learn more
Email *
I agree that I have read and fully understand the above statements and have marked my answer below. *
What is your full name? *
How did you find out about us?
Instagram Handle ?
What is your website? (only if you have one)
Phone Number? *
Address *
Address Line 2 *
City *
Zip/Postal Code *
Country *
Date of Birth (DD/MM/YYYY) *
Occupation *
Have you experienced a sound bath before? *
What services are you seeking? *
My goals *
The cost of services starts as low as $100, can you afford the investment at this time? *
Are you willing to commit to a minimum of 5 weeks of coaching? *
Private Coaching Sessions are on a weekly basis, and are only held Tues-Thur evenings between 2-5pm PST. Would you have the availability ? *
Is there anything you would like to share about yourself or your interest in our services? *
Emergency Contact ? *
Emergency Contact Phone Number ? *
What injuries or limitations do you currently have or have in your medical history? (For example: joint injuries, arthritis, asthma, allergies, etc.) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Music Changing Lives. Report Abuse
Google Forms