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Reiki Client Intake Form

Please fill out and submit the following form at least 24 hours prior to our session.

Client Information

Name

Phone No.

Email

Address

Date

Why do you wish to receive Reiki healing?

List any medications and/or treatments you are currently receiving:

Can you describe what a typical day looks like for you? Please include work, hobbies, sleep times, activities (including types and durations) meal times, menu and amounts, as well as who you most frequently engage with on a daily basis.

Upload a Photo of You Here

Upload File

Disclaimer

I understand that Reiki sessions are for the purpose of reducing stress and relaxation. Also, I understand that a Reiki session is not a substitute for a psychological or physical diagnosis and/or treatment. A Reiki practitioner does not diagnose conditions, nor prescribes or performs any medical treatment, nor interferes with the treatment of any licensed medical professional. It is recommended that I see a licensed physician or licensed health care professional for any psychological or physical ailment.

I confirm my knowledge and consent to the above disclaimer.

Thanks for submitting!

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