Sekhem-Seichim Reiki (SSR) Session intake form

Please fill out this questionnaire completely. This form is confidential and for (SSR) Session purposes only. It will help me to better help you!

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Email *

Name:  

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Date of birth  *
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Business Name (if applicable) if not applicable, please just type n/a

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Address:

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Required
City, State Time Zone 
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Phone Number *

 Desired method for Sekhem-Seichim Reiki (SSR) Sessions

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If Other, What method would you like to use for your SSR sessions 

What are the two best days and times for your  SSR sessions?

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Are you presently under a doctor’s care? 

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If yes, please describe *if no just put N/A*


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Do you have any existing medical conditions?

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If you answered yes, please specify *if no just put N/A*

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Are you currently taking prescription medication?

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If Yes, Please specify *if no just put N/A*

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Do you have any allergies or sensitivities?
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If yes, please specify *if no just put N/A*
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Have you undergone any recent surgeries or medical procedures?

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If Yes, Please specify *if no just put N/A*



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Are you currently experiencing any physical symptoms or discomfort? If Yes, Please specify
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Are you currently experiencing any emotional or mental health challenges? If yes, please describe:
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What are your goals or intentions for the SSR session?
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Do you have any specific areas of focus or concerns you would like to address during the session?
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Do you have any preferences or requests regarding the session environment *like music etc*
I understand that Sekhem-Seichim Reiki (SSR) is a complementary healing modality and is not a substitute for medical treatment. I acknowledge that I have read and understood the information provided, and I consent to participate in the SSR session.
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I understand that the information shared during the session will be kept confidential and will only be used for the purpose of providing SSR services.
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Is there any other information you would like to share or anything else I should be aware of before the session?*if no just put N/A* *

I, [Please type your name below] hereby acknowledge that the information provided above is true and accurate to the best of my knowledge.



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