New Client Form / Reiki Session
Please tell me a little about yourself!
I will contact you within 24 hours for a 5 minute chat to find the best time for your first session!
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Email *
First and Last Name *
Address, City, State, Zip code *
Contact number *
Text message okay? *
Emergency Contact (Name, relationship, and phone number) *
Are you under a physician's care? (Please note ~Reiki is not a replacement for professional health care. Reiki should be received as a complement to a physician's care.)
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Have you ever had a Reiki session? *
Would you like to share what brought you here today? Do you have a particular area of concern? *
Are you sensitive to fragrances or perfumes? *
Are you sensitive to touch? Energy can be hands on or indirect, or both. *
Favorite Color? *
Favorite type of music or song? *
How did you hear about Discover Reiki Energy?
Statement: 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. *
Privacy Notice: No Information regarding any client will be discussed or shared with any third party without written consent of the client, or parent/guardian if the client is under 18. *
Please sign (type first and last name) as confirmation that you have read both the Statement and Privacy Notice *
A copy of your responses will be emailed to the address you provided.
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