Marin Reiki Questionnaire
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
City
Preferred Contact Method
Email
Phone call
Text message
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact
*
Name and contact info
Reiki
What brings you to Reiki?
What are you hoping to receive from Reiki?
Stress Reduction
Emotional Balance
Relaxation
Energy Clearing
Spiritual Growth
Better Sleep
Anxiety Support
Grief Support
Burnout Support
Physical Relaxation
Life Transition Support
Chakra Balancing
Curiosity/First Time Experience
Other
Health And Wellness Background
What is your Stress Level
Very Low
Mild
Moderate
High
Overwhelming
Are you currently experiencing any of the following?
Anxiety
Depression
Fatigue
Insomnia
Chronic Pain
Headaches
Digestive Issues
Emotional Overwhelm
Trauma Recovery
Grief
Hormonal Imbalance
Burnout
None of the above
Other
Are you under medical care?
Yes
No
Are there any conditions I should be mare aware of?
Are you taking any medications that may affect your comfort during sessions?
Reiki and Holistic Experience
Have you experienced Reiki before?
Yes
No
Unsure
If yes, how was your experience?
Have you worked with other wellness modalities
Meditation
Acupuncture
Massage Therapy
Breathwork
Therapy/Counseling
Sound healing
Yoga
Energy Healing
Spiritual Coaching
None
Other
Session Preferences
What type of environment helps you feel safety and most relaxed?
Quiet Sessions
Gentle Conversation
Guided Meditation
Intuitive Feedback Afterward
Are there any sensitivities I should know about?
Sound Sensitivity
Light Sensitivity
Fragrance Sensitivity
Touch Sensitivity
Temperature Sensitivity
Other
Emotional & Energetic Intentions
What would you like to release, shift, or invite into your life right now?
How connected do you currently feel to yourself emotionally and spiritually?
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Is there anything weighing heavily on your heart or mind lately?
Consent & Wellness Disclaimer
Client Acknowledgment
*
I understand Reiki is a complementary wellness practice and is not a substitute for licensed medical or mental health care.
I understand no medical diagnosis or treatment is being offered.
I understand the results vary from person to person.
Logistics
Preferred Session Type
In-person
Distance Reiki
Either
Preferred Appointment Times
Weekdays
Evenings
Weekends
How did you hear about Marin Reiki
Google
Instagram
Referral
Friend/Family
Event
Other
Is there anything else you'd like me to know before your session?
Submit
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