Client Intake
Thank you for scheduling a Reiki or Yoga Nidra session with Lightning Peak Wellness! Before we get started, please answer a few questions.
Sign in to Google to save your progress. Learn more
Name: *
Today's date: *
MM
/
DD
/
YYYY
Your phone number: *
Date of birth: *
MM
/
DD
/
YYYY
Your email address:
Emergency contact name and phone number: *
How did you hear about Lightning Peak Wellness?
Please state your current primary concerns and rate their intensity (1=hardly notice symptoms, 10=symptoms are unbearable): *
Are you pregnant? If yes, how far along and are there any concerns? *
Do you suffer from chronic pain? If yes, describe. Is there anything that makes it feel better or worse? *
Have you had any significant injuries or surgeries? If so, please list: *
Do you have a pacemaker? *
Do you have diabetes? *
Do you have any allergies or sensitivities to scents or oils? If so, which scents? *
Please mark any symptoms that you are currently experiencing:
Have you ever had energy work or Reiki performed before? If yes, how long ago and what was the purpose and outcome?
What are your goals for this session? Please describe what you would like to accomplish with these treatments: *
Please list any questions, concerns, or requests you would like me to address before your session: *
Are you okay with the use of music, essential oils, crystals, hands-on, and hands-off touch? *
If at any time during the session you feel unwell or uneasy, please let me know. You’re welcome to provide insights/experiences during the session if it will assist in the session, or we can discuss it after the session.
Clear selection
Client acknowledgement: By typing your name below, you agree that you have completed this form as honestly and completely as possible, and will advise if anything changes at any time; you understand that Reiki is a natural, non-invasive modality to help bolster your own ability to heal and should not replace urgent or essential medical treatment by a licensed medical practitioner. Your signature also indicates your consent to receive hands-on treatment. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy