Reiki Intake Form

Name

First NameLast Name

Birth Date

MonthDayYear

Gender

MaleFemale

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?

Pain reliefRelaxationAddressing a traumaOther

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

Reiki is a healing technique that uses the universal life force energy to balance the subtle energies within our bodies to heal and contributes for balanced physical, mental, emotional, and spiritual being. Reiki is not a replacement for traditional medical treatment. During a Reiki session, your Reiki practitioner will lay their hands on 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. The effects of Reiki are cumulative in which regular Reiki treatments can invite significant improvement. Regular sessions support well-being in every way. 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.