How did you hear about me?
Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Address
City, State, Zip code
Date of birth
MM
DD
YYYY
Time of birth
Place of birth
Emergency contact & number
What is your occupation?
What is your intention for our sessions? Please share..
Please rate your current stress level?
low
medium
high
How is your sleep pattern? How many hours?
Are you currently on any medication for the issue? If so, what is the medication(s)?
Are you currently under a physician’s care? Is it for this condition or something else?
Are you participating in any other type of therapy to address this issue? Please list.
Please note: Because Pandora Star is a strobing light, there are some contraindications for its use. It is contraindicated for people with light sensitive seizure disorders like epilepsy, suffered a concussion in the last year, have had a stroke, diagnosed psychological or psychiatric condition (including psychosis), laser treatment to your face within the last month, or on photosensitive medications. Please consult your healthcare provider prior to your session if you have concerns or questions. A hypnagogic light experience is neither medicine nor psychotherapy. Upon arrival to SBW we will have a consent form for you to fill out prior to the experience. Do not hesitate to reach out if you have any questions.
May I include you in our community email list for promotion of my services, events, and products ?
I promise to not spam or give your personal information to any third party, whatsoever.
Yes please!
No thanks.