Reiki Client Information Form

First and Last Name*

Address

Cell phone*

City, State, Zip

Email (optional)

example@example.com

Emergency Contact*

Current Medications and dosage

Are you currently under the care of a physician? If yes, physician's name: How did you hear about us? Have you ever had a Reiki session before? If yes, when was the last session? Number of previous sessions

If yes, physician's name

How did you hear about us?

If yes, when was the last session?

Number of previous sessions

Do you have a particular are of concern?

Are you sensitive to perfumes or fragrances?

Are you sensitive to touch?

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, or interfere with the treatment of a licensed medical professional. I understand that Reiki does not take place of medical care. It is recommended that I see a licensed physician or licensed health care 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 can heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long-term imbalances in the body sometimes require multiple sessions 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 with any third party without written consent of the client or parent/guardian if the client is under 18.