Reiki Intake Form

Name

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemaleOther

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What are your goals for receiving Reiki?

Are there any injuries, surgeries, or recent health conditions that you feel the need to share?

Are you currently under the care of a physician?

YesNo

Have you ever had a Reiki session before?

YesNo

Are you sensitive to fragrances?

YesNo

Are you sensitive to Touch?

YesNo

I understand that Reiki is a simple & gentle, hands-on Energy technique that is used for stress reduction and relaxation to align the subtle energy systems within our bodies and contributes to a balanced physical, mental, emotional, and spiritual well-being.

During a Reiki session, your Reiki practitioner may place their hands on or just above your body in a series of hand positions to deliver Reiki energy. You might feel a floating sensation, emotional release, increased relaxation, enhanced sense of balance, centeredness, and calm, go on a meditative journey or fall alseep. Each persons session is unique to them.

I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have.

I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

If you experience any pain or discomfort during this session, immediately inform the practitioner.

Please sign below if you acknowledge the given information and give your consent to recieve the treatment.

Clear

Consent for underage client:

I am the parent or guardian of the client, who is under the age of 18, and by clicking the box I give permission for them to receive the chosen Reiki modality.