NEW CLIENT CONSULTATION FORM

NEW CLIENT CONSULTATION FORM
Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Gender*

FemaleMaleNon-BinaryNon-Gender ConfirmingOther
Preferred Pronouns*

She/HerHe/HimThey/ThemOther
Allergies or Sensitivities?*
Have you heard of Reiki or energy work before?

YesNo
What would you like to achieve from your treatment?
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?
FUTURE APPOINTMENTS/CONTACT
May I call/text you at the provided phone number to confirm future appointments?

YesNo
May I contact you via mail/email about future promotions and news?

YesNo
DISCLOURSURE

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. Incense, candles, and essential oils may be used. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this professional from liability and assume full responsibility thereof.
Signature*

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FUTURE APPOINTMENTS/CONTACT