New Client Intake Form

Name (required)

First NameLast Name

Date of Birth (required)

Date

Address (required)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number (required)

Please enter a valid phone number.Format: (000) 000-0000.

Email (required)

example@example.com

Emergency Contact (required)

First NameLast Name

Phone Number (required)

Please enter a valid phone number.Format: (000) 000-0000.

Please answer the following questions to the best of your knowledge:

How did you hear about us?

Have you ever had an energy healing session before?

Do you have any allergies or sensitivities we should be aware of (perfumes, essential oils, incense, bright light, noise, heat, cold, etc.) ?

What are you hoping to achieve from receiving Reiki (better sleep, less anxiety, pain reduction, better overall wellness, grounding/centering, revive stagnant Chakras, etc.)?

Reiki Treatment Consent:

I understand that Reiki is a holistic healing technique and is not a substitute for medical or psychiatric diagnosis and treatment. By signing below, I consent to receive Reiki treatment from Life In Balance Reiki, LLC.

Client Name

First and Last NameDate

Description of Reiki Treatment: Reiki involves the gentle laying on of hands or non-touch energy transfer to facilitate relaxation, stress reduction, and overall well-being. The practitioner may place their hands lightly on or above various parts of the body to channel Reiki energy. Treatment done through physical touch will be conducted in a professional and respectful manner.

Benefits of Reiki: Reiki is believed to promote relaxation, reduce stress, alleviate pain, and enhance overall physical and emotional well-being. However, individual experiences may vary, and there are no guaranteed outcomes.

Confidentiality: All information disclosed during the Reiki session will be kept confidential and will not be shared without your consent, except as required by law.

Cancellation Policy:
If you need to cancel or reschedule, please provide at least 24 hours' notice prior to your scheduled appointment. This advance notice helps us offer the time slot to another client who may be waiting. Cancellations made less than 24 hours before the appointment or missed sessions will incur the full session fee, which cannot be applied to future bookings. This policy is in place out of respect for your time and ours. We appreciate your understanding and cooperation.

Payment Policy:
Reservations are not confirmed until full payment is received. To secure your session or event space, full payment must be received at least 24 hours in advance. If payment is not received by the deadline, the practitioner may release or reschedule the appointment at their discretion.

By signing and dating below, you confirm that you have read, understood, and agree to the payment and cancellation policy, and the statements above. Thank you!

Client Signature

Date Signed

Date

New Client Intake Form

Client Information