New Client Intake Form

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Reiki is a holistic practice which brings Mind, Body & Soul into balance. The following questions will ensure your session is structured around your specific needs.

ABOUT YOU

FIRST Name
*

LAST Name
*

Date of Birth *

YYYY

What is your primary reason for the visit?

If you would rather not discuss this in detail, feel free to leave this section blank.

Have you ever experienced a Reiki session? *

Yes

Are you sensitive to touch? *

Reiki can be delivered without having any physical contact at all. Let me know if you would prefer a hands-off session.

Yes, please limit physical contact

Are you sensitive to perfumes or fragrances? *

If you are sensitive, please let me know so I avoid using essential oils during your session.

Yes

BODY

I have found when I begin a session with gentle movement, it gets the life blood moving and is conducive to a more intense session.

How many times a week are you physically active?

ALL day EVERY day

1 - 3 times a week

4 - 6 times a week

NEVER

MIND

Our minds can become very busy, so busy some clients have trouble being in the moment. If this sounds like you, no problem. I will begin the session with a visualization technique to bring your focus inward. This will help facilitate a more relaxed state of being.

Do you enjoy any of the following activities?

Meditation

Mindfulness

Relaxation Techiques

Breathwork

Reading

Hobby

Other:

SOUL

Soulwork is the path of reuniting yourself with your True Nature.  When you learn how to listen to and reclaim your True Nature, or Soul,  you experience what awakened beings through the ages refer to as Nirvana: the ability to transcend suffering, embody unconditional love and peace while creating a life of authenticity.  

It's important for us to understand our Outer World is but a reflection of our Inner World.

How often do you take time out for a religious or spiritual practice?

EVERYDAY

2 - 3 times a week

4 - 6 times a week

NEVER

Do you have any questions or concerns you would like to address before the session?

By placing a check mark in the boxes you are acknowledging you understand the information in its entirety. *

I understand Reiki is a simple, gentle, hands-on energy technique which is used for stress reduction and relaxation.

I understand Reiki 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.

I understand Reiki does not take the place of medical care. It is recommended I see a licensed physician or health care professional for any physical or psychological ailment I may have.

I understand Reiki can complement any care I may already be receiving.

I also understand the body has the ability to heal itself and to do so, complete relaxation is beneficial.

I acknowledge 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.

Required

CONFIDENTIALITY *

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 years of age.

I understand my sessions are completely CONFIDENTIAL.

Required

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