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Reiki Client Intake Form
Full Name
Phone
Email
Birthday *
Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Emergency Contact Name & Phone Number
Current Medications and dosage
Are you currently under the care of a physician?
YES
NO
If yes, physician’s name:
How did you hear about us?
Have you ever had a Reiki session before?
YES
NO
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?
YES
NO
Are you sensitive to touch?
YES
NO
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.
Your Signature
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Today's Date
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 under18.
SUBMIT FORM
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