Reiki Client Information Form
Name: (Please Print) _____________________________________________ Phone (home): ________________ Cell phone or evening: ________________ Address: _______________________________________________________ City, State, Zip: _________________________________________________ Email (optional): ________________________________________________ Emergency Contact: _____________________________________________ Current Medications and dosage: ____________________________________ _____________________________________________________________ _____________________________________________________________ Are you currently under the care of a physician? __ Yes __ No If yes, physician’s name: ___________________________________________ How did you hear about us? ________________________________________ _____________________________________________________________ Have you ever had a Reiki session before? __Yes __No If yes, when was your last session? ____________ Number of previous sessions ______
Do you have a particular area of concern? ______________________________ _____________________________________________________________ _____________________________________________________________ Are you sensitive to perfumes or fragrances? ________________________ Are you sensitive to touch? _________________
I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, 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 licensed 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 do 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.
Signed: ________________________________ Date: _________________
Privacy Notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.