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

Street Address Line 2

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?

Yes No
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
Date
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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Privacy Notice:

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