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New Client Intake Form

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

Birthday
Year
Month
Day
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
Do you have any diagnosed medical conditions or physical limitations?
Yes
No
Are you currently pregnant?
Yes
No
Do you have any pain or discomfort?
Yes
No
Do you have any allergies or sensitivities (e.g., scents, oils, fabrics, smoke)?
Yes
No

Reiki Session Preferences

Have you ever had Reiki before?
Yes
No
Do you prefer hands-on Reiki or hands-off (hovering above the body)?
Hands-on
Hands-off

Disclaimer and Consent

I hereby give my consent to participate in this reiki treatment session and understand that the services provided by my chosen reiki practitioner are intended to provide relaxation and reduce stress.

 

I understand completely that the services provided during this reiki treatment session are in no way a substitute for traditional medical treatment or advice. I am fully aware that my chosen reiki practitioner will not offer any diagnosis or recommend any medical treatment or prescribed medication.

 

I understand that I must continue to have regular medical check-ups as part of my overall personal health care plan; and I should contact my own certified and licensed medical physician/doctor/health care professional for any physical or psychological ailments or concerns that I may have in order to get proper medical advice.

 

I agree and understand that my participation in this reiki treatment session is voluntary and that at any time during the session I can choose to end my participation. I also understand that I may experience 'self-healing reactions' during the 48 hours following the reiki treatment session.

 

I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential and will not be shared with anyone without my written permission.

 

Finally, I understand that by providing this informed consent I am assuming full responsibility for participating in this reiki treatment session and I hold harmless both my chosen reiki practitioner and the facility/location where the services are provided.

Date
Year
Month
Day
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Disclaimer: Reiki is a complementary wellness practice and is not a substitute for medical care.

Lindsay Giles, Reiki Master

Lake Echo, NS

Copyright © 2026 Lotus Leaf Reiki & Chakra Healing

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