RavenLani Reiki Healing's Intake Form

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Please fill out the Intake form. By answering these questions it helps RavenLani to pre-determine which chakras need more attuning or aligning to ultimately balance the energy of the chakras. Ultimately, I will do a deeper assessment when performing the energy healing.
If you have any questions while completing this form, please send an email at ravenlanitarot@gmail.com or text 678-489-1124.

If you have not already done so, please order your session prior to filling out this form. https://ravenlanitarot.com/products/reiki-healing

Email *

First Name

Last Name

Birthday

YYYY

What brought you to seeking out Reiki? *

Which areas do you feel need improving? *

Ability to Align and Recenter Self (for healing or manifesting)

Ability to Believe in Self

Acknowledging Self-Worth

Connecting with Intuition/Inner Voice/Higher Self

Establishing Boundaries (romantic and non-romantic)

Expressing Self

Feeling Powerful

Feeling Safe and Secure

Having a Healthy Relationship with Money/Finances

Increasing Confidence

Increasing Self-Love

Positive View about Self

Releasing Grudges

Releasing Pent Up Feelings

Releasing the Past

Speaking Up for Self

Thinking Clearly + Being Able to Concentrate

Required

What blockages have you been experiencing? *

Anxiety

Abandonment

Fear of Intimacy

Feeling Disconnected, Lost, & Hopeless

Feeling Powerless

Headaches

Holding onto Grudges

Inability to Express Self

Inability to Find Life Pleasurable

Inability to Meditate

Inability to be Truthful

Insomnia

Jealousy + Envy

Lack of Gut Instinct

Lack of Stability/Foundation

Low Self-Esteem + Confidence

Sexual Anxiety

Shyness

Required

Prior to your session (in-person or distance), please drink plenty of water and wear minimal to no jewelry. *

I understand

I do not understand

Are you pregnant or planning to get pregnant? *

Yes, I am pregnant

Yes, I am trying to get pregnant

No, I am not pregnant nor trying to get pregnant

I am fully aware that Reiki healing and attunement does not take the place of professional medical or psychological assistance. *

Yes, I understand

No, I do not understand

Today's Date *

YYYY

Send me a copy of my responses.

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