Virtual Reiki Intake Form

Full Name*

First NameLast Name

Email*

example@example.com

Cell Phone*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Have you ever had a Reiki Session before?*

YesNo

Do you have difficulty lying on your back? :*

YesNo

Are you comfortable with hands on healing/touch?*

YesNo

What is your goal for your reiki session?*

Is there a particular area of the body where you have tension or discomfort?*

Is there anything else that I should know prior to your session?

I understand that the Reiki that I reiceve is provided for the basic purpose of relaxation and relief of tension and stress. If I experience any pain or discomfort during this session, I will immediately inform Sara Nelson so that adjustments can be made for my level of comfort. I futher understand that Reiki should not be construed as a substitute for medical examination, diagnosis or treatment. I should see a physician or other qualified medical specialist for any physical or mental ailment that I am aware of. I understand that Sara Nelson is not qualified to diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of a session should be construed as such. I affirm that I have stated all of my known medical conditions and answered all questions honestly. I agree to keep Sara Nelson updated as to any changes in my medical history and understand that there shall be no liability on the therapist's part should I fail to do so.

Signature*