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Reiki Client Intake Form
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Client Name:
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Address:
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Phone:
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Email:
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Emergency Contact & Phone #:
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Date of Birth:
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Reason for seeking Reiki Treatment:
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Other Medical or Complimentary Treatment or Medication being used:
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Medical History/Issues:
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Specific comfort needs during Reiki Treatment: (example - cannot lie on back, need pillow under knees, etc.)
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How did you hear about Reiki of Greater Boston?
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Reiki of Greater Boston-Healing for Body, Mind & Spirit
160 School Street, Suite 1-1, Waltham,MA 02451
508.335.3814 * reikiofgreaterboston@gmail.com * reikiofgreaterboston.com
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