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Reiki - Client Intake 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.

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Ivan Dutta
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2K views1 page

Reiki - Client Intake 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.

Uploaded by

Ivan Dutta
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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- Reiki - Client Intake Form

Name (Please Print):_____________________________________________________________

E-mail:__________________________________________________________________________

Mailing Address:__________________________________________________________________

City:__________________________________________________ State:_______ Zip:__________

Phone: ____________________________

Emergency Contact:_______________________________ Phone:________________________

How did you hear about my services? _____________________________________________________________

Have you ever had a Reiki session before? Yes____ No ____. If yes, date of last session: ____________________

Reason you are coming for Reiki and goal for this session:_____________________________________________

____________________________________________________________________________________________

Do you have any particular area of concern? ________________________________________________________

Do you have any difficulty lying on your back for the entire session? Yes_____ No_____

Are you sensitive to perfumes or fragrances? Yes _____ No _____ Are your feet sensitive to touch? Yes____ No____

Are you comfortable with a light touch during a Reiki session? Yes ____ No ____
(please indicate if you prefer hands-off treatment)

Do you have any additional comments or questions before we begin your session? ______________________

__________________________________________________________________________________________

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. I understand that Reiki does not take the place of medical or psychological
care. I understand that Reiki can complement any medical or psychological care I may be receiving.
I also understand that the body as 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.

Signature____________________________________________ Date _____________________


(If client is a minor a parent or guardian must sign)

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.

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