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Reiki Intake Formtest test2024-01-11T14:27:48-07:00

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)
If yes, how do you think it affected your health? (please click all that apply)

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)
MM slash DD slash YYYY
Consent(Required)
By checking this box I understand that the reiki I receive is provided for the basic purpose of relaxation and relief of tension and stress. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that adjustments can be made for my level of comfort. I further understand that reiki should not be construed as a substitute for medication examination, diagnosis, or treatment, and that I should see a physician or other qualified medical specialist for any physical or mental ailment that I am aware of. I understand that reiki therapists are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapists part should I fail to do so.

Studio Hours

Mondays 5:45am – 9:00pm
Tuesdays 8:45am – 9:15pm
Wednesdays 5:45am – 9:15pm
Thursdays 10am – 7:45pm
Fridays 5:45am – 9:00pm
Saturdays 8:45am – 1:15pm
Sundays 11:30am – 7:00pm

Please note that these hours reflect when the studio is open for the first and last classes of the day. Regular studio hours for product sales and appointments varies by day.

Visit Us

10451-99 Avenue #307

Fort Saskatchewan AB, T8L 0V6

Contact

info@thespaceyoga.ca

780.912.3415

The Space is located on Treaty 6 Territory and Métis Nation of Alberta Region 11, the traditional and ancestral land of the Nehiyaw (Cree), Denesuliné (Dene), Nakota Sioux (Stoney), Anishinaabe (Saulteaux) and Niitsitapi (Blackfoot) and Métis. We acknowledge, respect and celebrate the collective histories, languages and cultures of the First Nations, Métis, Inuit and all First Peoples of Canada. We are committed to advancing reconciliation and are in deep gratitude to those whose territory we reside on.

Safe Space Alliance progressive-flag Best in Fort Saskatchewan<br/ >Indigenous Tourism Alberta

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