Reiki Session Client Intake Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
Date
Appointment
Have you ever had a Reiki session before?
Yes
No
If yes, when was your last session?
How satisfied were you with your last session?
Number of previous sessions?
Are you currently under the care of a physician?
Yes
No
If yes, provide physicians name:
If yes, provide physicians name.
Do you have a particular area of concern?
If yes, are there any areas other than the obvious ‘inappropriate areas’ that you would not like to be touched? (i.e Face/Throat/Feet):
Please check any conditions you have now or have had in the past:
High blood Pressure
Diabetes
Low blood Pressure
Heart Attack
Stroke
Low back pain
Varicose veins
Headaches
Arthritis
Thyroid disease
Allergy to nut oils
Skin infections
Blood clots
Ulcer
Intense stress
Osteoporosis
Bursitis
Seizure/Epilepsy
Bleeding Con
Eating disorder
Other:
I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. 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 complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. 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 heal itself.
I understand
I do not understand
Name
First Name
Last Name
Client Signature
Continue
Continue
Should be Empty: