Reiki Client Information Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Would you like to be added to our email newsletter to receive updates on services and well-being events? I do not share your contact information and the newsletter is typically only sent 1-2 times per month.

Emergency contact (name/number)

Are you currently under the care of a physician?

How did you hear about us?

Have you ever had a Reiki session before?

If yes, when was your last session?

Number of previous sessions:

Do you have a particular area of concern?

Are you sensitive to pure essential oils?

Are you sensitive to touch?

Please Read:

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. 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 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.

Signature

Date

Privacy Notice:

No information about any client will be discussed or shared (including your email address) with any third party without written consent of the client or parent/guardian if the client is under 18.

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