Reiki Intake Form

Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender*

MaleFemaleOther

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Is your address the same as client’s? If Yes, please skip to next section.

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Are you currently under a physician’s care?*

YesNo

If yes, please indicate main physician’s name:

Does your physician support your desire for a Reiki Healing session(s)?*

YesNoUnkonwn

Please indicate if you (client) have any of the following concerns:*

Have you ever had a Reiki session:*

YesNo

What would you like the result of your Reiki session(s) to be?*

What additional benefits would you like to see from your Reiki session(s)?

Do you have sensitivities to fragrances?*

YesNoUnknown

Do you have a particular area of concern?*

YesNoUnknown

If yes, please let me know where / what:

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. Reiki is a healing technique that uses the universal life force energy to balance the subtle energies within our bodies, and contributes for balanced physical, mental, emotional, and spiritual being.

Reiki is not a replacement for traditional medical treatment.

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, heat or cold, emotional release, increased relaxation, enhanced sense of balance, centeredness, and calm.

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 ailment I may have. I understand that Reiki can compliment any medical or psychological care I may be receiving.

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 aid itself in healing.

The effects of Reiki are cumulative in which regular Reiki treatments can invite significant improvement. Regular sessions support well-being in every way.

If you experience any pain or discomfort during this session, immediately inform the practitioner.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless, Gina St. Aubin and Reikindled Light, from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

CLIENT: Please sign here if you acknowledge the given information and give your consent to receive the treatment.

LEGAL GUARDIAN: If client is under the age of 18 or unable to sign, and you, as legal guardian consent to the above, please sign here.

I do NOT agree to the terms / conditions of receiving Reiki Healing and releasing Gina St. Aubin / Reikindled Light from any liability.

I do NOT agree

Reiki Intake Form

Client Information

Legal Guardian Information

Emergency Contact Information

Current Medical Information

Reiki Experience

Consent to Receive Reiki / Release from Liability