TRE New Reiki Client Intake & Treatment Consent Form
IF THIS IS A MEDICAL EMERGENCY, PLEASE STOP RIGHT HERE AND CALL 911 IMMEDIATELY!

This form must be filled in and submitted by each NEW Reiki client of "The Reiki Expert" (TRE). All information must be accurate and complete (as much in detail as possible where applicable). It must be submitted prior to or at the time of the appointment before providing the TRE service(s).

If you are filling this form for someone else (e.g., "client") other than yourself, please ensure to accurately provide all information for the "client".

Submitting this form electronically or in person i.e., a soft copy OR a hard copy version) will be considered equivalent to providing your signature / approval / consent to completely and voluntarily share and comply with the information required and collected by this form.

Finally, this information will always be 100% confidential and stay only with TRE team and used only for the treatment and healing purposes. We will NOT share it with ANYONE else unless requested and preapproved in writing by the "client" or the person submitting this form on behalf of the "client".

If you urgently need an appointment OR if you can't fill this form in for any reason, please contact "The Reiki Expert" at +1 (630) 923-4115.

Thank you!
"The Reiki Expert"

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Email *
Full Name *
Email ID *
Home Address (MUST include): House Number, (Apt/Suite/Unit # if applicable), Street Name, City, State/Province, Zip Code, Country
(Example: 72 True St., Apt. 3C, Wishville, XZ 12345, USA)
 *
Cellular Phone Number *
Please provide your full phone number using + sign followed by your country code followed by your local phone number. For example, +1 (630) 923-4115 for the USA.
Birth Date *
MM
/
DD
/
YYYY
Your Height and Weight *
Sex Assigned at Birth *
Gender Identity *
Preferred Pronoun *
Would Like to Identify As: *
Emergency Contact Information (Name, Phone Number, Email ID) *
Relationship to Client *
Marital Status *
Employment Status *
Your Highest Level of Education *
Pre "Check-in" Information *
Yes
No
Diabetic
Recent Surgery
Sensitive to Touch
Sensitive to Fragrance
Taking ANY form of CBD
Pregnant or Planning to be Pregnant
Have Pacemaker
Have Any Implants
Need Special Assistance or Accommodation During Reiki Session
Need Help With "Pain Management"
Allow Updates Via Phone
Allow Updates Via Text/SMS
Allow Updates Via Email
If You Answered 'Yes" to the Above Question of "Pain Management", Please Provide the Pain Level on the Scale of 1 to 10
No Pain
Unbearable
Clear selection
Are You Currently Under the Care of Any Physician or APP (Advanced Practice provider)? *
If You Selected Any Option Other Than "No" Above, Please Provide Your Physician's or APP's Name and Contact Phone Number
Full List of All Current Medications and Dosage *
Please Also Include ANY "Over the Counter" (OTC) Medicines or Nutritional Products. If you are taking no medication or OTC product at all, please type "None".
Medical History (Check all the boxes that apply)
If you selected "Other" from the list below, provide its summary here:
 *
Required
Known Aggravating Factors *
If you selected any medical condition(s) above, provide what specific activities, conditions, environment, foods, or surroundings EITHER aggravate OR relieve EACH of those medical conditions. 

If there's no such factors OR if you are unaware of them, type N/A below.
Surgical History (Check all the boxes that apply)
If you selected "Other" from the list below, provide its summary here:
 *
Required
Family History (Check all the boxes that apply) *
Required
If You Checked Any of the Boxes in the Medical or Surgical or Family History Sections, Please Share As Much Relevant Information As Possible for EACH of Them
You are PRIMARILY requesting this Reiki treatment and healing session for (select the one that best represents your purpose of seeking this Reiki session) *
Have you ever had any Reiki treatment and/or healing experience? *
If You Answered 'Yes' to the Above Reiki Treatment and Healing Related Question, Please Share the Relevant Information (such as when, where, how many sessions, and for what purpose)
Are You Currently Undergoing (or, Have You in Past Undergone) Any of the Below Complementary and Alternative Medicine (CAM), Counseling, Therapeutic, or Healing Modalities? (Check all the boxes that apply) *
Required
If You Answered 'Yes' to the Above CAM Related Question, Please Share the Relevant Information
How Did You Heard About Us ("The Reiki Expert"? (Select all that apply). *
Required
Date of Submitting This Form *
MM
/
DD
/
YYYY
Date of Appointment (If Filling This Form AFTER Securing an Appointment)
MM
/
DD
/
YYYY
I Have Voluntarily and Accurately Provided all the Above Information to the Best of My Knowledge. *
Appointment Cancellation Policy and Charges *
I have fully read and understood the appointment cancellation policy and charges as mentioned in our website www.thereikiexpert.com/place-order and agree to comply with them.
Disclaimer and Privacy Policy *
I have fully read and understood the disclaimer and privacy policy as mentioned in our website https://www.thereikiexpert.com/our-services/disclaimer-and-privacy and agree to comply with it.
Help Us Avoid Spamming *
To ensure this form is not filled in by bots, please answer below the total of 3+2 = ?
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