Client Intake Form

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*

    Sex*

    Date of Birth*

    Occupation

    Relationship status

    Children & ages

    Women Only: Are you pregnant?

    Emergency contact

    Emergency contact's phone

    Are you currently under the care of a physician?*

    If yes write his phone number

    Please list any health issues or requirements you would like me to know about (include health restrictions, allergies, or other health concerns)

    Reason(s) for seeking treatment/what is happening in your life/Date of Onset?

    Are you taking any medication?

    Do you take recreational drugs and if so, what?

    Have you ever had a healing session before?

    How would you describe your healing experience?

    Did you notice any results?

    Amount Daily Intake
    Water

    Caffeine

    Alcohol

    Cigarettes

    Do you exercise?

    How many hours of sleep?

    What disrupts your sleep? How often does that happen?

    What is your typical diet like?

    What strategy do you use when you are stressed/angry or your nervous system feels dysregulated?

    Have you ever been in/going into hospital for surgery, mental or emotional illness?

    Please list any injuries you have or had

    Please list any traumatic or major life-threatening events that occurred in your life and what happened

    What makes you happy? What do you enjoy doing?

    What is your greatest fear?

    What would your child self say about your life today

    Is there anything you wish your parents knew about you that you feel they don’t?

    What would you like to achieve from these treatments?

    Are you sensitive to touch? (In-person only)

    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/AcquaintanceSocial MediaReferred 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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