Client Intake

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

Emergency Contact Phone

(###)

###

####

How did you hear about us?

Have you ever had a Reiki Session before?

Yes

If yes, when was your last session?

Spiritual/Religious orientation

Are you sensitive to perfumes or fragrances?

Are you sensitive to touch?

Agreement

I understand that Reiki is a simple, gentle, hands-on energy 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 licensed medical professional. I understand that Reiki does not take the place of medical care. 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 imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

Agreed

Signed Name

Agreement Date

YYYY

Privacy Notice:

No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

Agreed

What are your goals for today’s session?

What would you like to add, create or fulfill in your life?

Disclosures. Please read and check if you agree with the statements below. They are important to understand when receiving Reiki treatments.

Statement 1

Reiki is an integrative therapy that works in conjunction with traditional medical and psychological practices. Reiki doesn’t take the place of professional care, doesn’t diagnose conditions, prescribe medications nor replace licensed medical or specialized treatments.

Note agreement

Statement 2

Information shared or discussed during or following the sessions shouldn’t be treated as science, but rather as personal interpretation, opinion, experience, or beliefs designed to help empower one’s personal experience.

Note agreement

Locations of physical issues

In many cases, the location of pain, illness or any other type of issue can help us better understand the life area that needs healing, fulfillment and balancing. list any places where you have been recently or chronically experiencing pain, discomfort or physical issues you would like to heal or address:

Is there anything else that you would like to know, address, ask about, add or share?

Signature

Please enter your name as signature agreement for information on this intake form.

Signature Date

YYYY

client intake form

CONTACT