Simple Reiki Client Information Form

The intake form collects a client’s contact information, emergency contact, how they heard about the services, medical history as relevant to Reiki, areas of concern, preferences for touch during treatment, and an acknowledgement of Reiki’s limitations and benefits. The client signs agreeing to the treatment and privacy policy.

Name: (Please Print): _____________________________________

Phone (home): ____

Mobile: _______

Address: _____________________________________________

City, State, Post Code: ________________________________________

Email: _______________________________________

Emergency Contact: _____________________________________

How did you hear about me? _______________________________

Have you ever had a Reiki session before? Yes ___No ___

If yes, when was your last session? _______

Number of previous sessions: ________

Do you have a particular area of concern? __________________________

Are you sensitive to smells or fragrances? ____________________

Are you sensitive to touch? Yes ___No ___

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 perform 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.

Signed: ______________________ Date:________

Privacy Notice:
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.

The form is usually sent to your client before booking the Initial Consultation.

Image by Klara David Litschel from Pixabay


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