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Reiki Client Intake Form
Street Address Line 2
Postal / Zip code
Emergency Contact Name & Phone Number
Current Medications and dosage
Are you currently under the care of a physician?
If yes, physician’s name:
How did you hear about us?
Have you ever had a Reiki session before?
If yes, when was your last session?
Number of previous sessions
Do you have a particular area of concern?
Are you sensitive to perfumes or fragrances?
Are you sensitive to touch?
Check here if you agree with the following: 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 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.
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 under18.
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