reiki for fertility client Intake FormThis form is here to help me understand your journey and support you with care. Please share only what feels comfortable—your answers will remain private and confidential. Section 1: Contact Information * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Email * Emergency Contact Preferred Pronouns She/Her He/Him They/Them Other: Prefered Pronoun Other Choice Section 2: Fertility & Health Background How long have you been trying to conceive? Less than 6 months 1 - 3 years More than 3 years What stage best describes your current fertility journey? Trying to conceive naturally Currently in fertility treatment (IUI, IVF, etc) Pregnant after fertility treatment Exploring options / undecided Have you been given a fertility-related diagnosis? Yes (please share below if you'd like) No Prefer not to say Fertility-related diagnosis if you have and would like to share Are you currently taking fertility medications, hormones, or supplements? Please list any significant health conditions (thyroid, endometriosis, PCOS, prior surgeries, etc.) Section 3: Emotional & Stress Well-being How are you feeling emotionally about your fertility journey right now? What are your main stressors at this time? Fertility journey Work / career Family relationships Finances Health Other Describe other stressor if selected Do you have a support system in place? Yes (partner, friends, family, group, counselor, etc.) Somewhat No Section 4: Lifestyle & Self-Care How would you describe your sleep? Restful Sometimes restless Often poor Section 5: Spiritual / Religious Orientation Do you identify with a spiritual or religious orientation? Please share if you'd like to Section 6: Reiki & Session Goals Have you ever received Reiki before? Yes No What drew you to Reiki for fertility support? What would you most like to receive from Reiki sessions? Check all that apply Stress relief / relaxation Emotional Balance Support during fertility treatments Spiritual connection Physical healing / reproductive health support Other Other support details Are there specific areas of your body, emotions, or energy you would like focused on? Section 7: Comfort & Practical Notes Do you have any allergies, sensitivities, or physical needs I should be aware of? Closing Statement: Thank you for sharing your information. Reiki is a complementary practice that supports your physical, emotional, and spiritual well-being. It is not a substitute for medical care, and I encourage you to continue following the guidance of your healthcare providers. Reiki does not heal but it is complimentary to other healing modalities. Thank you! Peggy Gaines, RNLicensed REIKI MASTER Peggy Gaines is a Usui/Holy Fire® III Licensed Reiki Master Teacher with the International Center for Reiki Training. She received her Reiki Master training from William Lee Rand and Laurelle Gaia.Peggy is one of 43 Licensed Reiki Master Teachers in the United States. She has been teaching Reiki classes since 2010. Learn More
