Reiki Client Intake Form

Reiki Client Intake Form
Personal Information
Name

First NameLast Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which most closely describes your gender?
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reiki Session Information

The information that you provide below will be used to understand your needs and ensure a tailored experience to support your healing journey.
How did you hear about us?
Family, friends, Google, Instagram, etc.
Have you received Reiki before?
What are your goals or intentions for your Reiki session?
(Stress reduction, emotional healing, pain reduction, energy clearing, grounding, etc.)
Are there any injuries, surgeries, or recent health conditions that you feel I should be aware of?
Do you have any known allergies, asthma, general sensitivities, or sensory sensitivities?
(Incense or smoke, essential oils, touch, sound, etc.)
Reiki can be provided both while lying down and sitting. Please specify your preference.
Reiki sessions can be provided in one of two ways, hands hovering over the client or hands on the client. Please specify your preference.
Will you need any other accommodations during your session?
(Head pillow, knee bolster, etc.)
Terms of Service

I understand that Reiki is a simple, gentle 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. 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.

Privacy Notice

No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.
Consent and Signature

By signing below and submitting this form, I confirm that all the information provided is accurate and complete, that I have read and agree to the terms and conditions outlined above, and give consent to receive Reiki.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's date
Should be Empty:

Reiki Client Intake Form

Personal Information

Reiki Session Information

Terms of Service

Privacy Notice

Consent and Signature