Reiki Intake Form

Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender

MaleFemaleNon-binaryPrefer not to say

Email*

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Location/Time Zone*

This helps me schedule your session and tune in accurately

Have you received Reiki before?*

YesNo

What led you to book this session?*

Feel free to share what you’re hoping to receive or release.

Are there any specific areas you would like me to focus on (physical, emotional, or energetic)?*

Do you have any current medical conditions or injuries?*

Are you currently under medical care or taking medication?*

If yes, please elaborate.

Anything else you’d like me to know before your session?*

Reiki is a gentle, natural healing technique that channels universal life force energy to bring balance to the subtle energies within the body, mind, and spirit. It promotes harmony, relaxation, and restoration on all levels.

(During a distance Reiki session, the energy is sent remotely — meaning you can receive it from anywhere. Reiki is not limited by time or space; it flows through intention and energetic connection. You may wish to rest in a quiet space during your session to become more aware of the sensations as the energy flows)

You might notice gentle warmth, tingling, waves of peace, emotional release, or even deep relaxation. Some people feel the energy strongly, while others simply feel calm or refreshed afterward — all experiences are valid and unique.

The effects of Reiki are cumulative, and regular sessions can create profound shifts in well-being, balance, and self-awareness over time.

Please note that Reiki is a complementary healing practice and not a replacement for professional medical care.

If at any time you feel discomfort or wish to pause, you may message or notify your practitioner so the session can be adjusted.

By submitting this form, I understand that Reiki is a natural method of energy balancing and not a substitute for medical care. I take full responsibility for my own health and well-being and understand that the practitioner does not diagnose or prescribe.

I give permission for the practitioner to send Reiki energy at the scheduled appointment time.

I have read and agree to the above consent statement.*

Agree

Before your session -if through distance- find a quiet and comfortable space where you can fully relax without interruption. Please make sure your phone is off or on silent. You may wish to light a candle or insence, play gentle music, or hold a crystal that feels supportive.

Take a few slow, grounding breaths and set your intention for the session. It could be something as simple as “I am open to receive healing and balance.”

Then simply allow. Reiki energy will flow exactly where it’s needed most- physically, emotionally, and spiritually- bringing your system back into harmony.

Trust that your body and soul know how to receive this energy in perfect divine timing. 🌸💫

My Services (please select one)*

Distance Reiki SessionA gentle yet powerful energy healing experience designed to restore balance and harmony within your body, mind, and spirit. Using a completely hands-off method, Reiki channels universal life force energy into your energy field to support relaxation, release energetic blockages, and encourage your body’s natural healing process. Each session includes 30 minutes of Reiki followed by 30 minutes of open discussion and intuitive reflection. This time allows space to share what came through during the session: sensations, emotions, or insights — and to explore gentle ways to integrate the healing into your daily life. This session is done by DISTANCE. You can be nice and cozy at your home while I send you reiki from where I am.

$55.00

In Person Reiki SessionA gentle yet powerful energy healing experience designed to restore balance and harmony within your body, mind, and spirit. Using a completely hands-off method, Reiki channels universal life force energy into your energy field to support relaxation, release energetic blockages, and encourage your body’s natural healing process. Each session includes 30 minutes of Reiki followed by 30 minutes of open discussion and intuitive reflection. This time allows space to share what came through during the session: sensations, emotions, or insights — and to explore gentle ways to integrate the healing into your daily life. This session is done IN PERSON at my location.

$75.00

3 Session BundleA gentle, supportive journey designed to help you release stress, clear stagnant energy, and reconnect with your inner balance. These can be either in person or through distance. This package includes: • Three 1:1 Reiki sessions • Energetic clearing + nervous system soothing • Intuitive insights after each session • Intention setting at the start of the series Perfect for anyone feeling overwhelmed, stuck, or out of alignment. Each session builds on the last to create a calm, steady realignment in your mind, body, and spirit. After booking, I’ll reach out to schedule your sessions and set your intention for the series. ✨ Begin your realignment and return to your center. ✨

$160.00

15 minute consultationWant to chat before booking a session? This 15 minute consultation is done via Google Meet.

$ Free

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

Reiki Intake Form

Please select which type of session you would like to book

Payment Methods