Client Intake Form for Reiki/Healing Treatment

All information provided is private and confidential.

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.

(* Required)

    Full Name*
    Mobile or Home Phone number*
    Email*
    Address*
    City*
    Postal Code*
    Gender*
    MaleFemaleOther
    Date of Birth*
    Occupation
    Women Only: Are you pregnant?
    YesNo
    Emergency contact
    Emergency contact's phone
    Are you currently under the care of a physician?
    YesNo
    If yes, type your physician's contact number
    Please list any health issues or requirements you would like me to know about (include health restrictions, allergies, or other health concerns)
    Have you ever had a Reiki/Healing session before?
    YesNo
    Why are you seeking help?*
    Stress reliefAnxiety reliefPain reliefRelaxationHealing old wounds or traumaHealing from past/current relationshipsSpiritual growthOther
    What would you like to achieve from these treatments?
    Are you sensitive to touch? (In-person only)
    YesNo
    Do you have any additional comments or questions? Feel free to write them here or speak to me about them during our initial consultation.

    How did you find me? (check all the applicable)
    Search Engine (like Google)Friend/AcquaintanceFacebookLinkedInInstagramReferred by Physician/Complementary Health PractitionerOther

    Consent Form
    I understand that the Reiki/healing sessions given by Giancarlo Serra involve a natural method of energy balancing for the purpose of stress reduction, relaxation, and healing. Giancarlo Serra will not interfere with the treatment of a licensed medical professional.
    I also understand that it is not therapy or a replacement for medical treatment. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I have.
    I understand that I accept total responsibility for my own health care and maintenance. Nothing said, typed, printed, or produced by Giancarlo Serra is intended or meant to diagnose, prescribe, treat a disease, or take the place of a licensed physician.
    I understand the services offered and give permission to Giancarlo Serra to perform such services, and state that I have disclosed any information (health or otherwise) that may alter the effectiveness of services offered.
    I understand that if at any time I feel discomfort or have a problem with the session, it is my responsibility to voice my concerns.
    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.
    I understand that I must give at least 24 hours’ notice to receive a refund; and at any time during a session, I can request to stop session, though this may not entitle me to a refund.
    I have read and understand the terms and conditions in the cancellation policy.

    By signing below, I acknowledge and fully agree with all the above information.

    Signature date

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