Massage/Reiki Intake Form

Massage/Reiki Intake Form

Amy's Healing Arts
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date

MonthDayYear
MaleFemaleOther
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
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 or Massage or Hypnosis modality.
MassageReiki
Occupation: (This tells me what you do with your muscles all day.)
Pain reliefRelaxationAddressing a traumaStress reductionDeep Pressure, release knotsSpecific Issue/ area of concernOther
painSorenessStiffnessDizzinessSwellingNauseaNumbnessTingling
Sensitive to TouchSensitive to FragranceHad Reiki session beforeHad Massage beforeCurrently under care of a physicianAllergy to lotions/oilsAllergy to Essential oilsHistory of Seizures
Pregnant1st Trimester2nd Trimester3rd Trimester
Are there any injuries, accidents, surgeries, Illness, or recent health conditions that I should be aware of?
Please list any Major Medications or if you use topical hair grow serum:
Rate of Pain 1 to 10: (10 being Max)
Are there any injuries, accidents, surgeries, Illness, or recent health conditions that I should be aware of?
REIKI

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.

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 healthcare 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 I acknowledge that long-term imbalances in the body sometimes require multiple sessions in order to do.

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 receive the treatment.

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