Client Intake Form
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Full Name: *
Physical Address: *
Phone: *
Email: *
Please select all preferred contact methods: *
Required
Date of Birth
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/
DD
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YYYY
Referred by
Provide helpful data or medical history pertaining to reason for today's visit:
Have you had a Reiki session before?
Clear selection
Reiki typically involves a gentle, appropriate, hands-on technique. Are you ok with light touch?
Clear selection
Do you have difficulty lying on your front, back, or side?
Clear selection
If yes, please explain:
How often do you practice meditating?
How often do you exercise?
How many hours do you sleep each night? Is it restful? Please explain, if not.
Rate your level of stress (0=None and 5= Severe) regarding the following matters:
0
1
2
3
4
5
Work
Family
Health
Financial
Basic Life skills
Do you have a particular area of concern you would like to focus on today? Please explain.
What would you like to achieve out of today's Reiki session?
Please list any concerns you wish to discuss prior to your Reiki session.
Terms and Conditions:
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 agree that I will inform my practitioner of any significant health
changes prior to future appointments. 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 practitioners are providing Reiki at my request and are not responsible for the
outcome of the session. Reiki treatments are given fully clothed on a massage table.
Blankets, bolsters, and soft music may be used for additional comfort or relaxation
benefit.

Privacy Notice: No information about any client will ever be discussed or shared with any third party without written consent.
By submitting this form, you agree to the terms and conditions set out by this consent form and certify that the above information is true and correct. *
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