Please fill out this form as completely as possible so that I can better serve you.

Name

First Name

Last Name

Date

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Subject

Emergency Contact

First Name

Last Name

How did you hear about us?

Have you had a Reiki Session before?

Yes

Date of last session?

Number of previous sessions?

Do you have a particular area of concern?

Are you sensitive to fragrances?

If yes, please describe

Yes

Are you sensitive to touch?

If yes, please describe below.

Yes

Are you currently under a physician's care?

If yes, please provide name and contact info

Yes

Please list all current medications and dosage.

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I understand that Reiki is 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 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.

I agree

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.