Light & Balance Reiki Intake and Consent Form

Light & Balance Reiki Intake and Consent Form

Please complete this Reiki intake and consent form. Use the exact wording and structure from the provided PDF. All fields are optional unless clearly required in the source.
Client Information
Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How did you hear about me?
Emergency Contact
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reiki Experience and Session Goals
Have you received Reiki before?
If yes, when and with whom?
What brings you to Reiki at this time?
What are your goals or intentions for this session?
Your Stress Level

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Your Energy Level

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Your Overall Wellbeing

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Health History
Medications or supplements you are currently taking
Do you have any allergies?
If yes, please list allergies
Do you have any injuries, illnesses, or physical limitations that I should be aware of for your comfort and safety?
If yes, please explain injuries, illnesses, or physical limitations
Is there anything else I should know to best support you?
Primary Care Physician
Other Healthcare Practitioners
Do you have any medical conditions or concerns?
If yes, please explain medical conditions or concerns
Have you had any surgeries or hospitalizations?
If yes, please explain surgeries or hospitalizations
Are you currently pregnant?
If yes, what trimester?
Touch Preferences
Touch Preferences - Front
Touch Preferences - Back
I prefer hands-on Reiki (light touch) where indicated.
I prefer hands-off Reiki (no physical touch).
I am open to a combination of hands-on and hands-off.
Please ask me before touching sensitive areas.
Additional Notes (Touch Preferences)
Consent and Signatures
I have read and understand the informed consent statement
Client Signature
Client Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Practitioner Notes
Practitioner Signature
Practitioner Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Light & Balance Reiki Intake and Consent Form

Client Information

Emergency Contact

Reiki Experience and Session Goals

Health History

Touch Preferences

Consent and Signatures