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

Thank you for booking your Reiki/Breathwork 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.  (first-time appointments only)

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 *
Email address *
Phone Number 
(include area code and '+' country code if outside USA)
 *
Home Address 
(include city, state, zip + country if outside USA)
 *
Date of Birth *
MM
/
DD
/
YYYY
Emergency Contact: *
Emergency Phone: *
Which session are you requesting? *
Required
Have you ever experienced a Reiki or Breathwork session before? 
(select relevant to the requested session above)
 *
Required
If yes, when was your last Reiki / Breathwork session?
Do you have a specific area of concern ? 

What specifically would you like to accomplish with your Reiki/Breathwork 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 / Breathwork session?  

(provide only if you don't have an appointment already scheduled)
How did you hear about us?
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