Client Reiki Intake Form

Client Reiki Intake Form

Name(Required)
Address(Required)

** The following information will be used to help plan safe and effective Reiki sessions. Please answer the questions to the best of your knowledge.

Have you received Reiki before?(Required)
Are you on any medication?(Required)
Do you have any difficulty laying on your front or back?(Required)
What is your goal for todays reiki session? (please select all that applies.)(Required)
Do you experience stress in your work, family or other aspects if your life?(Required)

On a scale 1-10 (10 being the worst) how would you rate your stress level

Please enter a number from 1 to 10.
Is there a particular area(s) of your body where you experience tension, stiffness, pain or other discomforts?(Required)
Do you have any allergies or sensitivities?(Required)

Is there anything else about your health history that you think would be useful for your reiki therapist to know to plan a safe and effective reiki session for you?

Would you be ok with a hands on or hands off session?(Required)
Are you ok with the use of crystals in your session?(Required)
Have you been symptom free of any sickness or illnesses within the last 7-14 days?(Required)
Select date MM slash DD slash YYYY
Consent(Required)