Reiki -- Client Intake Form

Client Intake Form for Practical Reiki Treatments

If you need to cancel your appointment, it is required that you call or text within 72 hours of your scheduled time for a refund of your deposit, please do not e-mail.

Date:

YYYY

Name:

First Name

Last Name

Email:

Phone:

(###)

###

####

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender:

Birth date:

YYYY

Emergency contact:

Phone:

(###)

###

####

May we add you to our mailing list?

Referred by:

Might you have any difficulty lying on your back on a padded surface with support under your knees if required, for the entire maximum 1 hour treatment?

Would you prefer to have your session, or part of your session, in a chair?

Please list any health issues including health restrictions, allergies or other health concerns you would like me to be aware of:

List any other issues or concerns that you believe may affect your session(s) with me:

Have you had a Reiki treatment before?

If yes, when (approximately):

Number of treatments (roughly):

What for?

What worked well and what would you have liked to experienced differently?

What do you want to get from your Reiki treatments?

Are you looking for (check all that applies):

Stress relief

Anxiety relief

Pain relief

Relaxation

Healing old wounds or trauma

Healing from past/current relationships

Spiritual growth

Other

What specific physical issues would you like to improve or heal?

What specific emotional issues would you like to improve or heal?

What other things are you doing to support your health and overall well-being?