New Client Intake Form

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Are you a new or existing customer? *

I am a new client

I am an existing client (You will only need to fill-out this form once)

How did you hear about me?

Existing Client

Google Search

Facebook

Website

Other:

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Contact Information

First & Last Name *

Date of Birth *

YYYY

Time of Birth

Time

Location of appointment. Full street address or closest town or city. *

What is your preferred method of contact? *

Phone

Online (FaceTime, Zoom, Skype)

Required

Contact Number

E-mail

Have you ever experienced a Reiki session before?

Yes

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What is your primary reason for the visit?

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

Request for Appointment

Please specify the day of week that works best for you

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Time of Day - 1st Preference

I will do my best to accommodate your request, but please understand that may not always be possible.

Time

Time of Day - 2nd Preference

Time

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? *

The practitioner uses different essential oils such as Lavender, Sandalwood, etc. If you are sensitive, please let me know so I avoid using them during your session.

Yes

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 that 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 often 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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