Nourished Soul Reiki Intake Form

Reiki Intake Form

Please be completely honest and take time to consider your responses
Name

First NameLast Name
Email
example@example.com
Home Location
City, State, Country
Phone Number
Please enter a valid phone number.
Birth Date

MonthDayYear
Date
Birth Time

Hour Minutes

AM/PM Option
Birth Place
City, State, Country
Height
Weight
Emergency Contact Information

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
How did you hear about Nourished Soul? (Referral, website, social media, etc.)
Health History
How would you describe your current health?
Any current or previous serious illnesses, hospitalizations, surgeries or injuries?
Any allergies or sensitivities to food, medications, environmental or supplements?
Are you currently taking any pharmaceutical medications, drugs, supplements and / or herbal remedies? Please list along with the dosage.
Are you currently under the care of a healthcare provider? If yes, for what condition?
Do you have any diagnosed medical conditions (e.g., IBS, IBD, Crohn’s, Celiac Disease, SIBO)?
Are you currently working with any holistic healers, helpers, or alternative therapies, and what treatments have been beneficial for you in the past, even if you’re not currently using them?
Any current or past mental health concerns (e.g., anxiety, depression, PTSD)?
Any current inflammation, pain, stiffness, or swelling?
Are you pregnant? Is there a possibility you could be?

YesNoMaybe
Lifestyle
In a typical day, how many hours do you spend doing the following?

Please select one
Sleeping
What is the quality of your sleep?

Sleep through the night, wake restedWake up 1-2 times in the night, wake restedWake up throughout the night, wake unrestedInsomnia, difficulty falling/staying asleep- tired throughout the day
Screen Time (phone/tablet/tv)
Working
Self Care (meditation, grounding, praying, painting, singing, etc)
Exercising
What role do sports and exercise play in your life?
How would you rate your current stress level?
What are your main stress sources (work, family, health)?
Do you meditate or practice mindfulness? Describe how you fill your cup and practice self-care.
Nutrition
How much water do you drink daily?
How would you describe your current diet?
Do you cook? What percentage of your food is home-cooked?
Where does your non-home-cooked food come from?
Do you eat fermented foods (e.g., yogurt, kefir, sauerkraut, kimchi)? If yes, how often?
How often do you consume processed foods, fast foods, or sugary snacks?
Do you consume a lot of artificial sweeteners, soda, or caffeine?
Do you regularly drink alcohol? How many drinks per week? Please be honest (no judgement)
Do you smoke cigarettes? If yes, how often? Do you partake in recreational drugs or have any major addictions?
Spiritual and Emotional Well-being
Do you feel connected to your body, mind, and spirit?
Are there specific emotional or spiritual concerns you’d like to address?
Do you have any fears or concerns about receiving Reiki?
Client Preferences
Are you comfortable with light touch, or would you prefer no touch?
Any sensitivities to scents, oils, or music?
Preferred areas of focus during the session (if any).
Additional Comments
Is there anything else you would like to share?
Reiki Service Acknowledgment and Consent Form
Welcome to Nourished Soul Reiki Services! Before we begin your healing journey, please review the following key points to ensure a clear understanding of our services:

Acknowledgment of Complementary Therapy: I understand that Reiki is a complementary therapy and is not a substitute for medical treatment, diagnosis, or professional healthcare. I will continue to seek medical advice and treatment from my healthcare providers as needed.

Consent to Receive Reiki: I consent to receive Reiki, understanding that it is a gentle, non-invasive therapy that promotes relaxation and energy balancing. I acknowledge that my participation is voluntary and that I can withdraw consent at any time.

Confidentiality Agreement: I understand that all information shared during Reiki sessions will be kept confidential. The practitioner will not disclose any personal details without my consent unless required by law.

Release of Liability: I release the practitioner from any liability or responsibility for any outcomes, results, or reactions experienced during or after the Reiki session. I acknowledge that I am participating voluntarily and am responsible for my own health and well-being.
By signing below, I confirm that I have read, understood, and agree to the above statements.

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All of the facts in this form are true to the best of my knowledge and beliefs

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Reiki Intake Form

Health History

Lifestyle

In a typical day, how many hours do you spend doing the following?

Nutrition

Spiritual and Emotional Well-being

Client Preferences

Additional Comments

Reiki Service Acknowledgment and Consent Form