Client Questionnaire

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Thank you for taking the time to reflect and fill out this questionnaire. This is for me to know a bit about you, for you to reflect before our first session, and for you to know a bit about my practice. Hopefully you have explored my website and we have had a conversation on the phone.

I am a cis/hetero/white woman, in my 40s, I am married to the father of my child, I am also a stepmother. I have empathic qualities and have been affected by the family patterns of addiction and codependency. I have a deep desire and drive to keep learning and evolving, and I value the power of energy awareness, practice and community.

I am here to hold space with Reiki and listen to your speaking as well as listen to my intuition during our times together. I have studied and practiced holding space & listening, and I have practiced Reiki for almost a decade and I keep learning more about the history of Reiki and how to share it with most integrity as a white woman practicing a Japanese hands on healing technique.

I am not here to fix, but rather hold space for you to connect to your truth, your highest self, to trust and listen to your intuition as you move through life. It is an honor to do this work and share it.

Email *

Name (First, last, and pronouns) *

Is there anything you would like to share about the intersecting identities you hold? (i.e. gender, racial identity, age, sexual orientation, ability -mental or physical-, etc.)

What is your experience with energy work? Have you practiced Reiki? Have you received energy support from others? Whether that is Reiki, acupuncture, psychic work, cranio sacral or other modalities. What questions do you have for me, if any? If you are filling this out and we have already worked together in the past, has anything changed about your experience with Reiki and energy work?

Would you say that you are sensitive to other people's energy? This can show up as feeling the emotions of others, feeling drained when around others, or heightened feelings of anxiety when around others. This can also be labeled as empathic.

Yes (please give an example below)

Other:

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If you answered yes to the question above, do you have tools that you use to set energetic boundaries with people? Please explain. :)

Many people work with me to support the "quieting or calming" of the thinking mind, which is often in a state of "worry" or "fight or flight". Does this resonate for you? Explain if so.

The collective energy is challenging right now, and we are surrounded by ways to escape, which can lead to addiction. There are many accepted or "normal" addictions in our society, like work, technology, alcohol and cannabis. Do you use any substance to escape and numb out? No shame here, just an inquiry.

I see addiction as one of the most culturally accepted, denied, and prevalent human condition, resulting in dysfunctional families and relationships. Where does addiction show up in your family? This can be addiction to alcohol, drugs, work, screens, other people (codependency). You may or may not be aware of it (it can even be a grandparent) these are family patterns that I see as important to be aware of while working on energetic healing. Please share any patterns you are aware of in your family/lineage. I am here to support healing these patterns in ourselves.

We are spiritual beings living in human bodies, and we all have experienced some kind of trauma in our lifetime, and it varies how our bodies hold onto or let go of the trauma. Trauma can also be passed down from our ancestors, and can be held on from past lives. With the practice of Reiki, it can support the release of trauma energy in your body/mind/spirit. Is there any trauma that is coming up for you to release? This can be an experience from childhood, an accident, a past relationship with a narcissist, a family pattern, or an accumulation of experiences. Please share if there is anything coming up for you that you are ready to release.

Is there anything I need to know about your trauma that is triggering for you so that I can hold space for you in a more compassionate way? For example, I ask you if you are okay with touch during your session (gentle hands laying on your body over the blankets). If touch is at all triggering, please let me know. Of course I do not touch private areas. There may be even language that is triggering for you that I can avoid using. If you are aware of anything, please let me know!

Do you have any physical injuries, chronic pain, or areas where energy is held in your body that you would like me to know? Headaches? Digestion? Back?

Many people decide to work with me because they feel "stuck" in some part of their life. Does this term resonate with you and do you have a goal to become "unstuck" in any part of your life?

What is your daily self-care? Do you see any practitioners for self-care like massage or therapy? Are you part of any supportive communities or groups? Do you have a meditation practice? What is it? Do you desire better self-care practices in your daily life?

Do you have a spiritual practice? This may be part of your self-care explained above. Do you connect with something greater than yourself, whether it is God/Goddess/The Universe/Mother Nature/Guides/Angels/Fairies/Universal Energy?

Today's Date *

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Address *

Phone number *

Thank you for taking the time to read this form and complete the information. I look forward to working with you! Please leave any info you would like below or contact me with any questions. With Gratitude, Tekla

A copy of your responses will be emailed to the address you provided.

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