Reiki Intake Form

Please fill out the following form prior to session.

First Name

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

Initials

Phone

Emergency Contact

Are you under a physician's care

Have you ever had a Reiki session

Do you have a particular area of concern

Address

Current Medications

Physician's name

When was your last session

Are you sensitive to touch and/or smell

I understand that Reiki is a simple, 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 licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can compliment 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 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.

Signiture

Thanks for submitting!