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Intake Form: Animal Reiki Clients
THANK YOU FOR CHOOSING ALL IS ONE WELLNESS ARTS FOR YOUR ANIMAL COMPANION'S NEEDS. THESE FORMS ARE QUITE COMPREHENSIVE TO ALLOW US TO PROVIDE THE BEST POSSIBLE CARE.
I am a professionally licensed and insured practitioner. I adhere to the highest ethical standards of practice and compliance with national and state laws regarding my profession. Please note that my care is not a substitute for appropriate veterinary care.
ANIMAL REIKI CLIENTS: PLEASE FILL OUT THE FORM BELOW.
(EQUINE PHYSIOTHERAPY CLIENTS: RETURN TO WEBSITE TO FILL OUT THE EQUINE PHYSIOTHERAPY FORM.)
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Date
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MM
/
DD
/
YYYY
Name (First & Last)
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Your answer
Email Address
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Your answer
Phone Number
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Your answer
Animal's Name
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Your answer
Species (if selecting 'Other', please write in species)
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Dog
Cat
Other:
Sex
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Neutered Male
Spayed Female
Intact Male
Intact Female
Breed (if a cross, please describe your best guess)
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Your answer
Year born (approximate, if unknown)
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Your answer
Was this animal ever abused, neglected, or a rescue?
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Your answer
How long have you owned or cared for this animal?
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Your answer
Name of animal's veterinary clinic
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Your answer
Is animal current on vaccinations/deworming?
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Yes
No
Describe current living situation (e.g. inside only, outdoors only, kenneled, etc.)
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Your answer
Are there any other animals in the home?
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Your answer
Describe primary reason for seeking Reiki/bodywork/alternative therapies
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Your answer
Have you seen a vet for this issue?
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Yes
No
Describe any accidents/illnesses (please also list if there have been any surgeries or major diagnostic work)
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Your answer
Does your animal have any specific diagnosis FROM A VETERINARIAN, and for how long? (e.g. "kidney disease, diagnosed 2 yrs ago" or "hip dysplasia, confirmed by vet 6 mo ago")
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Your answer
Describe average amount of play or exercise animal gets in a typical week
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Your answer
Please describe diet, including brand, amount, and supplements
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Your answer
Has your animal ever bitten/clawed anyone?
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Your answer
Describe any habits your animal has that may affect health (e.g. eating rocks/trash; small dogs leaping off furniture; instigating rough play with larger animals)
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Your answer
Is your animal shy or nervous with new people?
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Yes
No
Sometimes
Does your animal dislike being touched anywhere? (e.g. hates tail touched, nervous around men, etc.)
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Your answer
Tell me about your animal's personality and their best trait
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Your answer
What are your hopes for this Reiki session?
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Your answer
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