Reiki Intake Form

Guidance Intake Form
Name*

First NameLast NamePronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Is it okay to leave a message?
Email*
example@example.com
Date of Birth*

MonthDayYear
Employer/Occupation
Emergency Contact*

First NameLast Name
Emergency Contact Phone*
Emergency Contact Relationship
Where did you hear about my services?
Have you experienced coaching, counselling or career counselling before?
Are there any medical conditions you are currently seeing a doctor for? If yes, please describe:
Method of Payment
NOTE: Reiki in-person Energy Healing sessions can be provided one of two ways. Hands on the client or hands hovering over the client. Please specify your preference.
Missed Appointment: I understand that emergencies can happen to anyone; therefore if an emergency keeps you from attending a session please call whenever possible to let me know of the circumstances. Such events as death in the family, serious accidents, serious illness and hospitalization are considered “emergencies”; otherwise, your appointment is reserved strictly for you. Please call to cancel at least 24 hours in advance or the full amount or a missed appointment fee will be charged.
Confidentiality: Whatever we discuss is strictly confidential. The only circumstances in which I would find myself needing to share information outside of our sessions with another professional or with authorities would be if I deemed you to be of any possible harm to yourself or another individual. If you wish for me to make contact or do research for you or leave messages with others I will need a release giving me permission to do so.
Client Signature*

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Date*

MonthDayYear
Should be Empty:

Guidance Intake Form