Artist Support

Name *

First Name

Last Name

Phone *

(###)

###

####

Have you ever received any mental health services? *

Choose any that apply.

Counseling/therapist/psychologist

Intensive Retreat (For Example: OnSite)

Rehabilitation/Treatment Center

None

Mental Health History *

Check any that apply currently or historically.

Depression

Trouble Sleeping

Trouble Concentrating

Low Energy/Drive

Self Harm

Suicidal Thoughts

PTSD

Anxiety

Anxiety Attacks

Addiction

Obsessive Compulsive Disorder

Excessive Guilt

Shame

Lonely

Nightmares

Agreement *

I, the undersigned, understand and acknowledge that I am voluntarily engaging in coaching and/or other services provided by Reality Co. I agree that these services are offered for my personal development and well-being and that any outcomes or decisions resulting from these services are my sole responsibility. I hereby agree to indemnify, defend, and hold harmless Syntax Creative, its officers, directors, employees, and affiliates from and against any and all claims, liabilities, damages, losses, or expenses (including reasonable attorney’s fees) arising out of or in connection with my participation in the services provided by Reality Co. By checking the box below, I confirm that I have read, understood, and agree to the terms of this indemnity and liability agreement.

I agree