New Client form

“Healing By Water” with Spike Bywater

Aquatic Therapist | Certified ThetaHealing® Master and Teacher

 Holistic Health Practitioner | Certified Massage Therapist

U.S. Navy Combat Veteran

Name *
Numbers must contain only digits and no other characters.
Date of Birth *
Date of Birth
Numbers must contain only digits and no other characters.
If yes, when is your due date?
If yes, when is your due date?
ie.: Body pain, joint pain, relaxation, spiritual development, letting go of attachments, experiencing something new etc.
Are you allergic to bees? *
Susceptible to motion sickness? *
Episodes of vertigo? *
Have you had any negative water experiences such as near drowning? *
Please read carefully: I understand that a session of any form of Aquatic Bodywork can be powerful and have profound effects, that when the body arrives at the level of relaxation possible in warm water and its normal tension holding patterns are released, there can, occasionally be reactions that can cause momentary discomfort. I also understand that being held as close as is required while being floated, can bring up issues that people have about intimacy. I will hold no one responsible for anything that happens to me during session. Ideally, the kind of heart space the session will help me into, and its continuity, will help me let go whatever comes up into its flow. I understand there have been no medical claims made for this session. I will give feedback the moment anything is uncomfortable. I understand that when I am brought to the end of the session, I am not required to immediately give feedback. I have read and agreed to the above statement and am listing above any conditions that might be affected by a session and agree to discuss with my practitioner:
Today's Date *
Today's Date

Client Application