Reiki Intake Form

Name

First NameLast Name

Birth Date

MonthDayYear

MaleFemale

Email

example@example.com

Phone Number

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

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pain reliefRelaxationAddressing a traumaOther

Are there any injuries, surgeries, or recent health conditions that you feel the need to share?

Do have any allergies or sensitivities to fragrances? If so, please list them here.

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

During a Reiki session, your Reiki practitioner will lay their hands on your body in a series of hand positions to deliver Reiki energy. You might feel a floating sensation, tingling, emotional release, increased relaxation, enhanced sense of balance, centeredness, and calm.

It is recommended you think about your intentions prior to your Reiki session; Your practitioner will talk it over with you at the beginning of your session or you can share it with her in advance.

What are some goals or challenges that you are working on?

What do you want to accomplish through your actions?

What do you want your journey right now to be about?

Reiki is not a replacement for traditional medical treatment. If you experience any pain or discomfort during this session, immediately inform the practitioner.

Optional: What are your intentions for this session?

Date

Please sign below if you acknowledge the given information and give your consent to recieve the treatment.