Stress - Teens- Intake Form

For the Parent / Guardian

Please complete Part 1 with your information and share what's been going on for your teen. You know them best.

For the Teen

Part 2 is just for you. Your answers are private — this session is a safe space, no judgment.

Part 1 — Parent / Guardian

Your Information

Your First Name

Your Last Name

Your Email

Your Phone

Relationship to teen

Parent Guardian Other

About Your Teen

Teen's First Name

Teen's Age

What's been going on for your teen? What made you want to book this session?

How long has this been present?

Recent (weeks) A few months 6 months – 1 year Over a year

Is your teen currently working with a therapist, counselor, or doctor?

Yes No Previously, not currently

Any health conditions or medications Nina should be aware of?

Does your teen know and agree to this session?

Yes, they're on board Mostly — they're open to trying They're hesitant but willing

Part 2 — Just for You (The Teen)

Hey. This part is just for you — your parent won't see your answers unless you want to share them. There are no right answers. You can be as honest as you want.

What's been stressing you out the most lately? (pick what fits)

School / grades Social stuff / friendships Family pressure Sports or activities My body / health Anxiety / racing thoughts Not sleeping well Social media / phone stuff Just feeling off — hard to explain Something specific happened

Where does stress show up in your body?

Tight chest Stomach / gut Shoulders / neck Headaches Jaw clenching I don't really notice it

How stressed are you feeling right now?

Chill

Max

Is there anything you're hoping to feel or get out of today?

Anything you want Nina to know before the session? (optional)

Parent / Guardian Consent

Tuning fork sound healing is a complementary wellness modality for teens and is not a substitute for mental health care, therapy, or medical treatment. Nina Torres is not a licensed medical or mental health provider. Sessions are non-invasive and include sound frequencies and optional breathwork guidance.

If your teen is working with a mental health professional, we encourage you to continue that support alongside these sessions.

As parent or guardian, I consent to this session for my teen. I have disclosed any relevant health or mental health information.

Your information and your teen's information are kept private and used only to support the session.

I consent to our information being stored securely at 5th Element Studio.

Parent / Guardian Full Name

Date

Nina will review this before the session. We can't wait to welcome your teen.

Stress & Teens
Session Intake

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