Reiki Intake Form

TO HELP US SERVE YOU BETTER, PLEASE FILL OUT THE FORM BELOW:
Reiki Energy Healing

Zen The Fuck Up!
Name

First NameLast Name
Date:

MonthDayYear
Date
Street
Apt#
State
Telephone:
Age:
Email:
example@example.com
For your safety throughout the session please answer what is appropriate
Do you smoke?
Do you drink alcoholic beverages?
Do you have high blood pressure?
Are you pregnant or trying to get pregnant?
Please list any prescribed medication you are currently taking
Please list any diagnosed psychological concerns
Please list any recent history of or ongoing contagious disease
Please list any serious physical injuries
Purpose of visit, symptoms or concerns
If you are experiencing pain please rank 1-10; 10 being most pain ever experienced
Other Comments or Symptoms:
Please communicate Comments after the session with your healer
Reiki is not a medical procedure:

Mordor will not diagnosed conditions nor prescribed or perform a medical treatment. She is only the channel in which your reiki will be received.

Please know that reiki sessions do not take the place of medical care. It is recommended that you see a licensed physician or licensed healthcare professional for any physical or psychological ailment you may have.
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