Client Intake Form

If you’re new to my healing practice, please complete this form after booking 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 and energy clearing session.

Vertical sequence of color swatches in shades of blue and purple.

Name

First Name

Last Name

Phone

(###)

###

####

What services are you interested in?

Select all that apply

Reiki

Emotion Release Sessions

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 find me?

Have you had a Reiki session before?

About when was your last Reiki session?

Have you had an Emotional Detox or similar energy work done before?

This may include a session with a certified Emotion Code, Body Code, or Belief Code practitioner.

What do you want addressed in your first session?

Items may include mental, physical, emotional, spiritual, or other 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 and other energy work such as the kind used in Emotion Release sessions are holistic, gentle healing techniques used for stress reduction and relaxation. I understand that energy healers do not diagnose conditions, prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that energy healing 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 and other holistic modalities 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

Client Intake Form

Be the change you want to see in the world.

Mystic Fox Healing Center