REIKI INTAKE FORM

Reiki Intake Form
All information is held in the strictest of confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Name*

First NameLast Name
Birth Date*

MonthDayYear
E-mail*
example.com
Phone Number*
Format: (000) 000-0000.
Any Allergies?*
Emergency Contact*

NamePhone Number
Is there any Medical Devices in the body?*
Any injuries, surgeries or recent health conditions that you feel the need to share?
PregnantBreastfeeding
StressAnxietyDepressionArthritisInflammationHigh/Low Blood PressureInsomniaDiabetesMuscle SpasmCancerHeadaches/migrainesStrokeJoint ReplacementNeuropathyFibromyalgiaHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains/StrainsDigestive ProblemsSitting long periodsOther
What would you like to achieve from your session ?*
ConstantOff/OnAt RestWith ActivityOther
StiffnessMuscle spasmDisc HerniationOther
PainBursitisArthritisCan't Raise Arm
WristFingersPins & NeedlesFingers go to sleepHands coldSwollen JointsSore JointsLoss of grip strength
Mid-BackBetween shoulder bladesUp/Down backAcross Mid BackPain with Breathing
Worse when LiftingWorse when StoopingWorse when StandingWorse when SittingWorse when BendingPinched Nerve in low backPain up/down low backPain across low backDisc Herniation
Pain in ButtocksPain deep in Hip JointDiagnosed bursitisDiagnosed arthritis
Pain down RIGHT legPain down LEFT legPain down BOTH legsCrampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed Arthritis
Client Agreement Information

Reiki is a healing technique that uses the universal life force energy to balance the subtle energies within our bodies to help heal and contributes for balanced physical, mental, emotional, and spiritual being.

During a Reiki session, your Reiki practitioner may lay the hands on your head, feet or knees in a series of hand positions to deliver Reiki energy. You might feel a floating sensation, tingles, 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 at any time during the session, you feel unwell, pain or discomfort, immediately inform the practitioner. You're welcome to provide insight/experiences during the session if it will assist in the session or you can advise upon the closure of the session.

I understand that Reiki is not a substitute for medical treatment or medications. I am aware that Jona Allen, does not diagnose illness or disease nor does she prescribe medications or recommend supplements. I understand that any suggestions that are provided to me should not be taken as a diagnosis or recommendation against the advice of a licensed physician or mental health professional.

Yntimate Li Ou LLC is managed by Certified Peristeam Facilitating Practitioners, Master Teacher Reiki Healers, Life Enrichment Specialists, Doulas, Medical Assistants and Health & Wellness Coaches; operating under Oregon’s “educational licensing exemption” under ORS 675.825(4)(a), which allows Alternative Practitioners and Counselors to practice legally in Oregon without a state determined license.
Yes please
Signature*
Date*

MonthDayYear
Should be Empty:

Reiki Intake Form