Client Intake Form
Welcome. This form helps us understand your current needs so your Reiki session is supportive, personalized, and grounded in care. All information is kept private and sacred. To book your session, simply fill out this form and once your appointment is confirmed, you'll receive an invoice via email, which must be paid in full prior to the session.
Your Name
*
First Name
Last Name
Date of Birth
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Time Zone:
About You
Have you ever received Reiki before?
yes
no
What brings you to Reiki at this time? (Choose all that apply)
Stress & anxiety
Emotional healing
Physical pain or tension
Post-surgery or trauma recovery
Sleep issues
Fertility / hormonal support
Grief or loss
Energetic reset or clarity
Spiritual alignment
Other
If you chose "other", please include the other options:
How are you feeling emotionally and physically right now? (Brief description or keywords are okay)
Your Intentions
What would you like to focus on during your Reiki session?(This helps us align energetically with your goals — feel free to speak from the heart.)
The Session
Do you prefer:
Lying down quietly during the session time
Receiving Reiki while going about your day
No preference
Would you like a follow-up summary or intuitive impressions after your session?
yes
no
Health Information
Reiki is a complementary therapy and not a substitute for medical care. Please provide accurate details to ensure a safe session.
Do you have any current or past medical conditions? (e.g., heart conditions, epilepsy, chronic pain)
Are you currently taking any medications or undergoing medical treatments?
Do you have any allergies or sensitivities? (e.g., to scents, oils, or touch)
Are you pregnant or nursing?
pregnant
nursing
n/a
Session Preferences
How did you hear about Well Rooted Living - Reiki?
Have you received Reiki before?
yes
no
What are your goals or intentions for this session? (e.g., stress relief, emotional balance, physical healing)
Agreement and Consent
Signature
Date Signed
-
Month
-
Day
Year
Date
Save
Submit
Should be Empty: