Client Intake Form

Please complete the below intake form prior to your session.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Please select session type

Private Reiki Session

Private Sound Healing Session

Private Reiki/Sound Healing Combo

What would you like the focus or intention to be for your session?

Are you sensitve to fragrance?

Are there any sounds/instruments you dislike?

(For Sound Healing)

Are you comfortable with a light touch during a reiki session?

Please indicate if you prefer hands off treatment

Have you ever had a reiki or sound healing session?

If yes, when was your last session?

Describe your challenges or concerns.

How did you hear about my services?

Do you have any additional comments or questions before we begin your session?

Do you have any metal in your body?

If yes, where?

Are you pregnant?

If yes, how far along are you?

Consent

It is my choice to receive reiki and/or sound healing and I understand that the practitioner will be using gentle sound/vibration on or around me and/or gentle touch for hands on reiki. I understand that practitioners do not diagnose conditions nor do they prescribe or perform medical treatments, prescribe substances, nor interfere with the treatment of a licensed medical professional. This is not a replacement for medical care. I understand that Reiki/Sound Healing can compliment 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 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. I have completed this form to the best of my knowledge.

Yes

Sign Name

Privacy Notice:

No information about the 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.