Reiki Client Registration Form

Reiki Client Information

Please fill in the form below
Name:

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number:

Area CodePhone Number
Cell Phone Number:

Area CodePhone Number
E-mail:
Birth Date

MonthDayYear
Previous Reiki experience
How did you hear of us?
Occupation:
In case of Emergency
Contact:

First NameLast Name
Phone Number:

Area CodePhone Number
Relationship:
List treatments or medications client is currently receiving and for how long?
Comments and history (physical problems, current or past injuries, life transitions):What you would like the reiki treatment to focus on.
Current outlook on life:
Life qualities you wish you had more of in your life:
I understand and agree to authorize Susan Grace Wisniewski to treat me with Reiki techniques and to retain the information provided above.
Signature
Date:

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

In case of Emergency