Reiki Intake

Reiki Client Information

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Name

First Name Middle Name Last Name
Date of Birth

Month Day Year
E-mail
Contact Number:

Area Code Phone Number

Address:

Street Address
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City	State / Province
Postal / Zip Code	Country

In case of emergency...
Emergency Contact:

First Name Last Name
Relationship
Contact Number

Area Code Phone Number
Taking any medications, currently?

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If yes, please list it here
How did you hear about this office?
Have you had a Reiki session before?
Date of last session

Month Day Year
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Number of previous sessions
Do you have a particular area of concern?
Are you sensitive to perfume or fragrance?
Are you sensitive to touch?
I understand that Reiki is a simple, gentle, hands-on-energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interefere with the treatment of a liscensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement at medical or psychological care I may be receiving. I also understand that the body has the ability to hel itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.
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No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.
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Reiki Client Information