Client Intake Form- All Questions are Required

Name

First NameLast Name

Email

example@example.com

Phone Number

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

Address of where Reiki Session will take place

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you had a Reiki session before?

YesNo

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

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

Do you have any specific areas of concern for your Reiki session?

Are you sensitive to touch?

YesNo

I agree to provide a clean, safe, and smoke-free environment in my home that is suitable for a 45-minute Reiki session, including adequate space for a zero-gravity chair and free from distractions or interruptions

Yes

Reiki Client Acknowledgment & Consent (Mobile Sessions)

I understand that Reiki is a gentle, hands-on (or hands-off) energy practice intended to support relaxation, stress reduction, and overall well-being. I acknowledge that Reiki practitioners do not diagnose medical conditions, prescribe medications, or perform medical or psychological treatments. Reiki is not a substitute for licensed medical care.

I understand that it is my responsibility to seek appropriate care from a licensed physician or qualified healthcare provider for any physical or psychological conditions I may have. Reiki may be used as a complementary practice alongside conventional or alternative medical care.

I acknowledge that the body has a natural ability to heal itself, and that deep relaxation may support this process. I understand that individual results vary, and that multiple sessions may be beneficial for addressing long-term imbalances.

For mobile Reiki sessions conducted in my home or chosen location, I agree to the following:

I give permission for the practitioner to provide Reiki services at the agreed-upon location.

I will ensure a safe, clean, quiet, and appropriate space for the session, free from hazards, interruptions, or unsafe conditions.

I understand that sessions may be adjusted or discontinued if the practitioner determines that the environment is not safe or suitable.

I consent to either light touch or non-touch techniques, and I understand I may request modifications or stop the session at any time.

I agree to communicate any physical conditions, injuries, sensitivities, or concerns prior to the session.

I understand that the practitioner maintains professional boundaries at all times and that the session is strictly for wellness purposes.

I release the practitioner from liability for any outcomes related to the Reiki session, except in cases of gross negligence.

I understand that payment, cancellation, and travel policies have been explained to me and I agree to those terms.

By signing below, I acknowledge that I have read, understood, and voluntarily agree to receive Reiki services under these conditions.

I have read, understand, and consent to my Reiki session with Jess Santos

Yes