‘Reiki’ New Client Information & Disclosure Form (Live Your Yellow Brick Road)

Thank you for booking your Reiki session with Joanne Klepal, Live Your Yellow Brick Road.

In order to maximize your time in session, please complete the attached information at least 24-hours prior to your first appointment.

Please submit your completed form by hitting the ‘SUBMIT’ button at the bottom of the page.  

To protect your privacy, DO NOT EMAIL THIS FORM!

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First Name *
Last Name *
Date of Birth *
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DD
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Email address *
Phone Number (include area code and '+' country code if outside USA) *
Home Address *
Emergency Contact: *
Emergency Phone: *
Have you ever had a Reiki session before? *
Required
If yes, when was your last Reiki session?
Do you have a specific area of concern ? What specifically would you like to accomplish with your Reiki session?   *
Are you currently under the care of a physician, psychotherapist, pathologist or any other licensed practitioner? *
Required
If YES, advise your physician's name & contact number:
If YES, please explain the condition(s) for which you are being treated and the nature of the treatment(s), including any medications.
Other comments, history or other relevant information we should know:
Are you sensitive to perfumes or fragrances?   *
Required
What are your preferred days of week and/or times of day for a Reiki session?  (provide only if you don't have an appointment already scheduled)
How did you hear about us?
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