New Client Intake Form

Please take a moment to fill out the form before your first appointment.

First name

Last name

Birthday

Year

Month

Day

Email

Phone

Preferred Method of Contact

Email

Phone

Text

Health Information

Please note that Reiki is a complementary therapy and not a substitute for medical treatment. This information helps me provide the best care for you.

Are you currently under the care of a health professional?

Yes

No

If yes, please explain.

Do you have any diagnosed medical conditions or physical limitations?

Yes

No

If yes, please list.

Are you currently pregnant?

Yes

No

Do you have any pain or discomfort?

Yes

No

If yes, please specify.

Do you have any allergies or sensitivities (e.g., scents, oils, fabrics, smoke)?

Yes

No

If yes, please specify.

Reiki Session Preferences

Have you ever had Reiki before?

Yes

No

What are your goals or intentions for this session?

Are there any areas of your body or energy field you would like extra attention on?

Are there any areas you would prefer to avoid?

Do you prefer hands-on Reiki or hands-off (hovering above the body)?

Hands-on

Hands-off

Do you have any specific concerns, emotions, or intentions you would like to address?

Confidentiality and Consent

All information provided on this form is confidential and will not be shared without your consent.

Reiki is a complementary modality and not a replacement for medical or psychological treatment.

By signing below, you acknowledge that you understand the nature of Reiki and consent to receive treatment.

Signature

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