Client Information Form
Eleonore Koury | Kampalpriya Kaur
Reiki Master Teacher/Therapist | Certified Kundalini Yoga & Restorative Yoga Instructor | Spiritual & Life Coach
Empowering individuals & groups with life enriching technologies, practices & retreats

The following is information regarding Reiki, Reiki Mentoring, Spiritual and Life Guidance, Kundalini Yoga and Coaching . Sessions can include one modality or a combination. Please indicate your preference below.

I understand that Reiki, or any of the above listed are stress reduction and relaxation techniques. I acknowledge that treatments administered are only for the purpose of helping me relax and to relieve stress.

Eleonore does not diagnose conditions, nor does she prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment I may have.

I also understand and believe that the body, mind and spirit has the ability to heal itself, and to do so complete relaxation is often beneficial. Long term imbalances in the body, mind and spirit sometimes require multiple treatments to reach the level necessary to bring the system back into balance. I understand and believe that self-improvement requires commitment on my part, and that I must be willing to change in a positive way if I am to receive the full benefit of treatments.

I acknowledge my commitment to my self-improvement process. I recognize that a treatment program must be followed to be truly effective, just as prescribed medication is only effective if taken as directed.

I understand that if I need to cancel a scheduled appointment, I will provide 24-48 hour notification. If an appointment is cancelled or rescheduled in less than 24 hours, I am responsible for paying the full rate for the service.

Electronic Signiture *
Required
Enter Initials *
Your answer
Please Complete the Following:
First Name *
Your answer
Last Name *
Your answer
Client's Representative
Your answer
Date *
MM
/
DD
/
YYYY
DOB *
MM
/
DD
/
YYYY
Address
Your answer
Email *
Your answer
Phone *
Your answer
Would you like to be on my email list *
Please indicate modality *
Have you ever received a professional reiki, and or massage/bodywork session? If so, when was your last session?
Your answer
What brings you to this session?
Your answer
Have you any recent or past injuries or surgeries?
Your answer
Have you any other physical conditions I should be aware of? What makes it better? What makes it worse?
Your answer
Do you have any of the following conditions? *
Required
Do you smoke? *
Do you use any substances for relaxation or stimulation, such as alcohol, caffeine, sugar, etc.? *
If yes, indicate which substance and how much
Your answer
List treatments or medications you are currently receiving?
Your answer
What are the current stressors in your life? What makes it better? What makes it worse?
Your answer
What current methods of self-care are you practicing (ie, yoga, tai chi, meditation, etc.)?
Your answer
What would you like to achieve in your sessions?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service