Client Contact Information
Sign in to Google to save your progress. Learn more
Email *
Today's Date *
MM
/
DD
/
YYYY
Full Name *
Email *
Address *
Phone number
Date of Birth *
MM
/
DD
/
YYYY
Marital Status
Have you ever had a Reiki session before? *
Required
Purpose of your session today.
Do you have a particular area of concern? *
Are you sensitive to perfumes or fragrances? *
Required
Are you sensitive to touch? *
Required
Disclaimer
I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or preform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement 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 often 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.

Privacy Notice:
All personal information is held securely in accordance with the appropriate legislation, is confidential and treated appropriately.
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.

I agree with the disclaimer and privacy policy. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy