Reiki Client Intake Form

Full Name

Phone

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

If yes, physician’s name:

How did you hear about us?

Have you ever had a Reiki session before?

YES

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

Are you sensitive to touch?

YES

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

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.

Reiki Client Intake Form

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.

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.