Reiki Adult Intake Form

Reiki Intake Form
Name

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemaleNon-binaryOther
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact: Name & Number
Do you have any recent injuries, surgeries, or other health conditions?
Current Medications*
Medical Information: Please check any applicable

AllergiesArthritisAnxietyBlood Pressure L / HChronic PainDepressionDiabetesEpilepsyHeadachesMetal ImplantsOsteoporosisPacemakerPregnantPTSDScent SensitivitySkin InfectionsTouch SensitivityVeracious VeinsOther
What are your goals for receiving Reiki?*

Pain reliefRelaxationAddressing a traumaAnxietyDepressionRelief from chronic illnessSleep dysfunctionOther
Have you experienced Reiki before?*

YesNo
Are you comfortable with light hand /sound tool contact?*
Are you comfortable with sound tools, crystals, and/or aromatherapy?*
How did you hear about us?
Anything else you'd like me to know?
Reiki is a healing technique that uses the universal life force energy to balance the subtle energies within our bodies to heal and contributes for balanced physical, mental, emotional, and spiritual being. Reiki is not a replacement for traditional medical treatment. It is not meant to diagnose any medical condition.

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

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

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Please select each square as your understanding of the statement.*

I understand Reiki is not a substitute for medical care or medicine.I understand the session is voluntary, and I may choose to end the session at any time.I understand that Reiki can complement medical care that I may be receiving. I agree to inform my practitioner of any health changes prior to appointments.I also understand that the body has the ability to heal itself, I acknowledge that long-term imbalances may sometimes require multiple sessions. I understand that my practitioner is doing this service at my request, and is not responsible for any outcome.
Date*

MonthDayYear
Date
You will receive an email confirming you submitted this form. If you receive any other emails, please do NOT open or click on them. If I have questions, I will email you directly. Please keep yourself safe! Any questions, message me before opening. Thank you!
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Reiki Intake Form