Reiki Intake Form

Full Name

First NameLast Name

Birth Date

Date

MaleFemale

Email

example@example.com

Phone Number

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

Spouse Name

First NameLast Name

Birth Date

Date

MaleFemaleN/A

Phone Number

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

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Yes, I have been to counseling in the past two yearsYes, I'm currently seeing a licensed therapistNeither applyOther

Explain "Other"

Is there any injuries, surgeries, or recent health conditions that you feel the need to share?

Please share why you and your spouse would benefit from a complimentary one-hour individual or joint Reiki session at this time.

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.

The effects of Reiki are cumulative in which regular Reiki treatments can invite significant improvement. Regular sessions support well-being in every way.

If you experience any pain or discomfort during this session, immediately inform the practitioner.

Reiki is a complementary wellness practice and is not a substitute for medical or mental health care. Participation is voluntary, and no guarantees are made regarding outcomes. By participating, I acknowledge personal responsibility for my well-being and release Circle of Arms, Ashes to Phoenix, and all associated practitioners from liability.

The Reiki practitioner will not place hands on you without first asking for your permission and will guide you through each step of the session to ensure your comfort and understanding.

Participants are encouraged to approach the experience with openness and receptivity to holistic healing. As a guideline for participation, individuals must have previously engaged in counseling or currently be working with a licensed therapist.

If you have not yet scheduled a therapy appointment or begun your healing journey, we kindly ask that you start that process and return after a few months of therapeutic support, at which time we would be honored to welcome you.

Please sign below if you acknowledge the given information and give your consent to recieve the treatment.(If no signature is present we will not be able to consider you as a participant)