Client Intake Form
Please answer the following questions
Welcome to Vitality Reiki!
First Name *
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Last Name *
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Email Address *
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Phone Number *
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Address (ex: 123 Main St) *
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City *
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State *
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Zip code *
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How did you hear about Vitality Reiki?
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Information & Waiver (please read and acknowledge)
Welcome to Reiki! The purpose of this form is to give you some basic information on Reiki.

What REIKI is
Reiki is a form of complementary Healing, which enhances the body's ability to heal itself.

What Reiki is NOT
Your practitioner is not a licensed physician. REIKI is a complement to 'healing arts services licensed by the state', i.e., it is a complement to more traditional western medicine provided by doctors, nurses and hospitals. As a complementary therapy, REIKI does not require licensing by the state. However, I am certified in REIKI and have been practicing for over six years.

Nature of the Services Provided
During a Reiki Session, The client lies down or is seated, fully clothed. The practitioner(s) place their hands on or above the body and allow the REIKI to radiate from the hands.

Theory of Treatment
Stress, trauma and illness restrict the natural flow of Ki or Chi life force energy through the body. By restoring KI to the body, Reiki rejuvenates the body’s ability to relax and de-stress, and supports its ability to heal itself. It is a way to ‘tune-up’ your energy to its healthiest state allowing for healing to take place.

In addition to the practitioner radiating the Reiki energy through their hands, sessions may involve the practitioners sweeping their hands above the body in various ways, or incorporating breath or vocal tones to break up energy blocks.


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 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 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.

I understand that reiki is entirely therapeutic and non-sexual in nature.

A copy of the above document is available upon request.

Do you understand and accept the terms of this waiver *
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