I'm S.H.E.'s Reiki Healing Confidential Client Case History, Intake, and Consent Form
***FOR REIKI SESSIONS ONLY*** Please complete this confidential Client Case History and Intake form to the best of your knowledge AFTER you have scheduled a Reiki Healing session with I'm S.H.E. If you have not booked a session yet, then please use this link to do so. You will not be seen by an I'm S.H.E. Reiki practitioner if you have not scheduled a session with us. Answering these questions accurately is important to help the Reiki practitioner understand which chakras may need more alignment than others and where to concentrate more energy during the session.
 If you have any questions while completing this form, then please send an email to ImSoulHealingEnergy@gmail.com or call/text 404-883-2188.
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Email *
Phone Number *
First Name *
Last Name *
Date of Birth *
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Who were you referred by? *
What is the first primary concern that made you request a Reiki healing session? *
Rate your level of concern. Level: 1 (hardly notice symptoms) to 10 (symptoms are unbearable) *
Hardly notice symptoms.
Symptoms are unbearable.
What is the second primary concern that made you request a Reiki healing session?
Rate your level of concern. Level: 1 (hardly notice symptoms) to 10 (symptoms are unbearable)
Hardly notice symptoms.
Symptoms are unbearable.
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Please list any significant accidents or injuries. Type N/A if this not apply. *
Please place a checkmark beside any conditions that apply (past or present): *
Required
Place a checkmark beside any psychological or physical symptoms that you currently experience:
Place a checkmark beside any areas below that you would like improvement in: *
Required
Below, please describe what you would like to accomplish with these treatments? *
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