Client Intake Form Name * First Name Last Name Date * MM DD YYYY Email * Have you had a reiki session before? Yes No If yes, when was your last session? How did you hear about my services? Who referred you? Are you sensitive to fragrance? * Yes No Are you sensitive to touch? Yes No I understand that Reiki is a 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 health care professional for any physical or psychological condition. 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. E-Signature * First Name Last Name 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 is under the age of 18. Thank you for your inquiry! We will be in touch shortly.
