New Client Intake Form

If you’re new to my Reiki practice, please complete this form when you book your first session. We’ll review your responses at the beginning of your appointment to ensure your experience is personalized and supportive.

All information you provide is kept confidential and used solely to help guide your healing session.

Name

First Name

Last Name

Phone

(###)

###

####

What services are you interested in?

In-Person Reiki

Remote Reiki

Both In-Person & Remote Options

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Current Medications and Dosages

Are you currently under the care of a physician or other medical professional?

Physician's Name/Office Name

How did you hear about me?

Have you had a Reiki session before?

About how many Reiki sessions have you had?

About when was your last session?

Please list what you want addressed in your first session.

This may include mental, physical, spiritual, or energetic issues.

Are you sensitive to perfumes, oils, fragrances, or incense?

Are you sensitive to light physical touch?

Although not absolutely required, there are instances where light physical touch may be used.

I understand that Reiki is a gentle energy healing 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 care from a medical professional. 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 energetic imbalances may require multiple sessions to facilitate the level of relaxation needed by the body to heal itself. No information about any client will be discussed or shared with any third party without written consent of the client or the client’s parent/guardian if the client is under 18.

By electronically signing this form, I certify that I agree to the above Terms.

E-Signature

Today's Date

YYYY

New Client Intake Form

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