INTEGRATIVE REIKI & SOUND HEALING INTAKE FORM
Personal Information
Full Name:
*
First Name
Last Name
Phone Number:
*
Format: (000) 000-0000.
Email Address:
*
example@example.com
Emergency Contact:
*
Session Experience
Have you experienced any of the following before?
Have you experienced any of the following before?
*
Reiki
Sound Healing
Breathwork
Meditation
Energy Work
None
Current Support Needs
What brings you to this session?
What brings you to this session?
Stress / Overwhelm
Anxiety
Back
Next
Burnout
Emotional Release
Grief
Relaxation
Mental Clarity
Nervous System Support
Spiritual Connection
General Wellness
Other
What would you most like support with during this session?
*
Physical Body Check-In
Are you currently experiencing any pain, tension, discomfort, or areas that need extra attention?
Headaches / Migraines
Jaw Tension
Neck & Shoulders
Upper Back
Lower Back
Chest Tightness
Back
Next
Hips
Fatigue
Sleep Challenges
Chronic Pain
Other
Please describe any physical concerns you'd like me to be aware of:
Sound Healing Considerations
Do you have any sensitivity to sound, vibration, frequencies, or loud noises?
*
Yes
No
If yes, please explain:
Are there any sounds or instruments you particularly enjoy or dislike?
Emotional & Energetic Support
How have you been feeling emotionally, mentally, or energetically lately?
Overwhelmed
Back
Next
Anxious
Burned Out
Emotionally Heavy
Grieving
Stressed
Restless
Seeking Clarity
Disconnected
Other
Are there any major life events, transitions, or challenges you would like me to be aware of?
Session Intention
What intention would you like to bring into this session?
*
Medical Considerations
Do you have any medical conditions, injuries, surgeries, implants, devices, or health concerns that may impact your session experience?
*
Back
Next
Session Enhancements
Are you interested in any of the following add-ons?
Crystal Support
Aromatherapy
No Thank You
Additional Information
Is there anything else you would like me to know before your session?
Consent Statement
I understand that Reiki and Sound Healing are complementary wellness practices intended to support relaxation, stress reduction, nervous system regulation, and overall well-being. These services are not intended to diagnose, treat, cure, or prevent any medical or psychological condition. I acknowledge that I have disclosed any relevant medical conditions, injuries, medications, sensitivities, diagnoses, or health concerns that may affect my participation and will notify the practitioner of any changes prior to my session.
Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: