Return to Spirit Reiki Healing LLC Client Intake, Consent & Energy Alignment Agreement
Please complete this intake form before your Reiki session. Provide accurate information and review all consent statements carefully.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Healing Experience
Have you previously received Reiki or energy healing?
*
Yes
No
What brings you to this session?
*
Emotional Healing
Stress / Anxiety Relief
Physical Discomfort
Spiritual Alignment / Growth
Trauma Release
General Wellness
Other
Current Care & Awareness
Are you currently under medical or psychological care?
*
Yes
No
If yes, please share anything you feel is important for your session:
Consent & Understanding
Please read each statement carefully and check to confirm your agreement.
Client Signature
Consent & Understanding
*
I understand that Reiki is a holistic energy healing practice that supports balance within the mind, body, and spirit.
I acknowledge that this service is not a replacement for licensed medical or psychological care.
I take full responsibility for my health and well-being and will seek medical advice when necessary.
I understand that each session is unique, and results are not guaranteed.
I consent to receive Reiki healing and energy work from Return to Spirit Reiki Healing LLC.
I release the practitioner from any liability related to the services provided.
Date
*
-
Month
-
Day
Year
Date
Full Name (Electronic Signature)
*
First Name
Last Name
Submit
Should be Empty: