Reiki Client Intake
Reiki is a non-invasive light-touch intervention with the purpose to reduce stress and encourage relaxation.
No healing claims are made for this therapy , as every individual reacts differently.
First / Last name
Email address
Phone number
Are you currently under the care of a physician?
Clear choice
Yes
No
If Yes, Physician's Name
How did you hear about me?
Have you had Reiki before?
Clear choice
Yes
No
If Yes, when was your last session?
Do you have Reiki:
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Regularly (more than 1x month)
Monthly
A few times a year
Please share any particular area of concern you may have today. (Mind, body, spirit. Personal or professional life. Possible stressors in life)
Are you sensitive to fragrance or aromatherapy.
Clear choice
Yes
No
Disclaimer: Energy healing, Reiki, is considered an alternative, complementary approach and does not replace the need for traditional medical care through your physician or licensed professional. You should not stop, add, or change any medication or traditional treatment, without the advice, consent and direction of your physician. You are advised to seek the care of a licensed professional for any physical, mental or emotional concerns.
Which aromatherapy do you like?
Please choose all that apply.
Select all
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Lavendar
Peppermint
Eucalyptus
Geranium
Other
It other, please list here:
I understand Reiki is a simple, hands-on 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 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 the long term imbalances in the body sometimes require multiple session in order to facilitate the level of relaxation needed by the body to heal itself.
Signature
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Date
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Privacy Notice:
No information about any client will be discussed or shared with a third party without written consent of the client or parent/guardian if the client is under the age of 18.
Verification
SUBMIT FORM
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