New Client Intake Form for Distant Reiki SessionCommentsThis field is for validation purposes and should be left unchanged.Name* First Last Phone*Home Address*Email* Date of Birth MM slash DD slash YYYY How did you hear about us?Are you currently under the care of a Physician, Psychiatrist or Psychologist? Yes NoIf yes, please provide name(s) and phone # below:DiagnosisCurrent Medications and dosageIf you have a particular area of concern, Please describeHave you had any traumatic experiences in this lifetime? Yes NoPlease describeDo you feel you’ve had any past life traumas? Yes NoPlease describeHave you ever had a Reiki session before? Yes NoIf yes, when was your last session? MM slash DD slash YYYY I understand that Reiki is a simple, gentle form of energy that is used for stress reduction and relaxation. I understand that the Reiki Practitioners do not diagnose conditions, nor do they prescribe or perform medical treatments, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to 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.Digital Signature*Date MM slash DD slash YYYY Privacy Notice: No information about any client will be discussed or shared with any third party without the written consent of the client or parent/guardian if the client is under 18.
