Calmante Reiki Therapy Client Intake

Calma Naturale Healing

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Form Date*

MonthDayYear

Birth Date*

MonthDayYear

Client Full Name*

First NameMiddle NameLast Name

Phone Number*

This is my:*

Parent Full Name if Client is Under 18

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail (Parent if Client is under 18)

Emergency Contact*

Phone Number*

Occupation

Medications

Allergies

Medical Information

Are you currently under Physicians Care*

NoYes

Physicians Name

Session Information

Have you ever had an Energy Healing Session*

NoYes

Approximate Date of last Session*

Please list types of Energy Healing Sessions you have had here:

Are you familiar with Sound Therapy*

If "Yes or Some What" please share a brief summary of your experience*

Do you have any implants?*

If "Yes" regarding Implants, please provide a brief summary of your Implants*

Do you have a particular area of concern*

Are you sensitive to Fragrance*

NoYes

Are you sensitive to touch*

NoYes

How did you hear about us? Can we Thank someone for recommending us?

Treatment Terms and Conditions

Energy Healing Therapy Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.
Please turn off your cell phone for optimal relaxation
You will remain fully clothed during the session, please wear comfortable garments you can move easily in
Your scheduled session is set aside for you. We do not double book appointment
Please reschedule your session if you are more than 15 minutes late
24 hour cancellation notice is required to avoid being charged for your session
You will have a consultation with your therapist to discuss your session
I understand that my therapist or I may end the session at any time for any reason
Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

I understand that Calma Naturale therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals.
I acknowledge that Reiki and Sound Healing therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.
It is my choice to receive this form of Therapy
I understand that treatment given is designed to provide me with the tools for my own personal Healing and my Therapist is not responsible for Healing me but supporting my desire to be healed
I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapist
I have stated my pertinent medical conditions, and will update the therapist of any changes in my health status.
- I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Calma Naturale and my therapist from any liability whatsoever arising from failure on my part.
By my electronic confirmation below, I agree to the Energy Healing Therapy policies and Client Agreement above.

No information about the 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.

Electronic Client Confirmation:

I agree that I have read all Information in this Form and Understand and Agree with the Calma Naturale Energy Healing Therapy Policies and Client Agreement Above

Client Initials and Date to complete Acceptance of Terms and Conditions

Acceptance Date

Date