REIKI TREATMENTS — INTAKE FORM

Name

First Name

Last Name

Date

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

DOB

YYYY

How would you rate your health?

Reason for your visit?

Please list any current injury/illness/surgery and/or chronic conditions.

Please list any past injury/illness/surgery.

What, if any, psychiatric or health concerns are you currently receiving treatment for? List any medications.

Please list any holistic therapies you’re participating in.

Where does your body hold tension? (e.g. neck, shoulders, stomach)

Have you ever had a Reiki treatment before?

What are your expectations for this session?

Please list any additional comments regarding your health and well-being.

I don't want to receive news and stress management tips via e-mail.

Reiki practitioners are not doctors and do not diagnose or treat for a specific illness or prescribe or adjust medication. Reiki is not a substitute for medical or mental treatment, but is a complement to most types of therapy. By pressing SUBMIT I give my consent to a Reiki session. I understand I may discontinue a session or sessions at any time. If I have been diagnosed by a licensed health professional as having any disease, injury, or mental condition, I understand I should inform the person who made this diagnosis about the sessions I will be receiving, and whether or not I intend to discontinue any treatment or therapy which had been previously ordered, prescribed or recommended by a licensed health professional. I understand that by discontinuing any such treatment or therapy, I assume responsibility for any negative outcome resulting from discontinuing that treatment or therapy.

Intake Form

REIKI TREATMENTS — INTAKE FORM