Raindrop Technique and
Vibrational Raindrop Technique Your Health & Wellness
Advocate
Intake Form
Full Name Date
Location of Appointment Phone
Email
May we add you to our mailing list? Yes // No
Important Note about Essential Oils and Allergies
There are no amino acid/proteins in Young Living Steam Distilled Essential Oils, so allergic reactions are not
possible. If you have a skin reaction to a Steam Distilled essential oil, it is a detox reaction or sensitivity.
However, Citrus Oils are Cold Pressed, and proteins remain in the essential oil, thus an allergy can possibly
occur with a citrus oil. Please confirm if you are allergic to any citrus fruits. Also, nuts crushed for fatty oils
that are used in our raindrop carrier oils will also contain proteins, thus an allergic reaction may occur if one
is allergic to the nut. Please inform us if you have an allergy to nuts and which kind. The standard Raindrop
session does not contain citrus oils.
There are some considerations we should review (if you have any of the following Allergies or Medical
Concerns) that could influence your Raindrop session and how we plan for it.
1. Allergies to any Citrus fruits?
2. Allergies to Nuts or Seeds? (If yes, we will adjust the carrier oil used.)
3. Allergies to anything else?
4. Currently Pregnant, trying to become Pregnant or Breast Feeding?
5. Hypertensive (High Blood Pressure)? Hypotensive (Low Blood Pressure)?
6. Currently are Epileptic, or have a history of Epileptic seizures?
7. Are on Cardiac medications or are a Transplant Patient?
8. Are a MS Patient (Multiple Sclerosis)?
Or have a neuralgia that makes you sensitive to heat?
If yes, what temperature do you want your “warm compress”? (Cold, Cool or Lukewarm)
9. Paralyzed in any of your limbs?
10. Lower Limb amputee? If so, we can perform Vita Flex on the hand or “phantom limb.”
11. Any back issues or back surgeries?
12. Currently having any rashes, skin sensitivities or open sores/wounds?
13. Any other issues, conditions or concerns I should know about before we begin? Describe Below.
Finding Freedom To Be Your BEST Self!
14. Pre-Evaluate: How do you feel Physically, Mentally and Emotionally before we begin?
Physically:
Mentally:
Emotionally:
Past History/Toxin Exposure/Detox (please circle all that applies to you):
1. Looking back at your life experiences and work history, have you ever been exposed to:
At home- Chemicals, pesticides, herbicides, photo chemicals, etc.?
At work- Beauty Shop, Auto Body, Professional Housecleaning, Farming, Hospitals, Road crews/
paving, Painting, etc.?
2. Do you Smoke? Yes // No Have you ever smoked? Yes // No
3. Alcohol Consumption? Yes // No How much?
4. Illicit drug use? Yes // No
5. Are you on any Medications? Yes // No
The essential oils used and the Vita Flex work performed along the spine during a Raindrop Technique can
bring about a detox reaction within the body that can last for up to seven days after your session. It is im-
portant to drink lots of water to stay hydrated every day, but especially after a Raindrop Technique session
to help keep detox symptoms to a minimum. The best way to remove unwanted toxins from the body is
through urine and sweat. The best way to accomplish this is to flush them out with plenty of clean water.
Be sure to drink at least half your body weight in ounces of pure water per day for the next seven (7) days.
(Tea, soda, sports drinks, alocohol, and other beverages are not pure water!)
Checklist
Have you read the “11 points for Raindrop Technique”? Would you like to proceed?
Some of the oils used during the Raindrop Technique can cause the skin to warm up or become
itchy. If this happens, please let me know right away so I can cool it down and it does not become
uncomfortable for you.
Are there any areas of the neck/shoulders/back you would like me to focus on today?
Review and Sign Informed Consent Form
Remove all metal
We could do an iTovi session before we begin. I may use one of your essential oil suggestions for
your raindrop session. Indicate if interested.
Please use the Restroom before we begin.
Measure Height of Client. (As the muscles, ligaments, and fascia of the back warm and soften with
the oil application and techniques used, the back will straighten a bit and we can see the
‘growth.’ Before and after measurements can be taken; this is not necessary.) Indicate if interested.
Post Session
* Facilitator observations during Raindrop Session:
* Re-measure client.
* Schedule future appointment.
Please call Sherry at 814-883-0006 if you have any questions/concerns or want to schedule another
session. Essence of Pure Living would like to help you be your best you!
Finding Freedom To Be Your BEST Self!
