Reiki Client Intake Form

Reiki Client Intake Form
Name*

First NameLast Name
Phone Number*
Email*
Scheduled Appointment Date*

MonthDayYear
How did you hear about me?*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Physician's Name*
Current medications and dosage*
About when was your last Reiki session?*

I've never had Reiki beforeLess than 3 months ago3-6 months ago6 months to a year agoOver a year ago
How many sessions have you had in total?*
Do you have a particular area of concern for this session?*
TERMS OF SERVICE

I understand that Reiki is a simple, gentle 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 interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal 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.

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.
Agreement*

I agree to the terms of service as described above.

Reiki Client Intake Form

Reiki Session Information