Reiki Intake

Intake Form (for returned clients)

* Indicates required field

Name *

First

Last

Email *

Today's Date (00/00/0000) *

Phone Number *

City and State *

Do you have any particular area of concern? (Optional) *

Were you issued a folder? *

Yes, I was given a folder No folder, This is my first session No folder has ever been given

Please be sure to bring your folder to your session *

Ok got it I lost or damaged my folder I never received a folder

When was your last Reiki Session? *

How are you feeling physically? *

How are you feeling mentally/emotionally? *

How are you feeling spiritually? *

Any changes since your last session? *

Yes No changes

Please list changes. *

Would you care to share a testimonial on your experience with us and on receiving reiki , If yes please add testimonial here. (Please share here) *

18. How should we list your testimonial? *

19. Your Professional Title (Optional) *

20. We have some exciting upcoming events. Please let us know if you are interested in any of the following. (Check all that apply) *

21. Consent to perform Reiki Treatment I understand that the treatment I am receiving is a stress reduction and relaxation technique and I acknowledge that treatment administered is only for the purpose of helping me relax and relieve stress. Reiki is not a diagnostic tool and a replacement for medical treatment. I understand that it is recommended that I see a licensed physician or health care professional for any physical or psychological ailment I may have. I understand that my Reiki therapist will not interfere with the treatment prescribed by a licensed medical professional. I also understand that this is not a massage therapy session and that I will remain fully clothed (except for shoes and/or socks) during the entire session. I also understand and I believe that the body has the ability to heal itself and to do so complete relaxation is often beneficial. Long term imbalances in the body sometimes require multiple treatments to allow the body to reach the level of relaxation necessary to bring the system back into balance. By signing below I acknowledge and fully agree with the above information for this and all subsequent Reiki treatments. *

Yes, you have my consent No, you do not have my consent

22. 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. Medical Disclosure: Energy healing is not medical treatment & does not replace appropriate medical care by a licensed professional. Energy therapists do not diagnose or treat medical conditions & will not interfere with treatment by licensed professionals. Energy healing is used only to balance energy fields of the body. It is your full responsibility to seek & use medical care as you would see fit to do without holistic complementary practices. *

Yes I understand I do not understand and need more clarity

23. Your name here indicates your signature. *

Reiki Intake Form

Intake Form (for returned clients)

"Where spirit meets community."