Reiki Client Information Form
Name: (Please print) ___________________________________________________________
Phone (home): ___________________________ Cell phone: _________________________Address: ____________________________________________________________________
City State Zip: ________________________________________________________________
Email: ______________________________________________________________________ Emergency Contact: ___________________________________________________________
Current Medications and dosage: ________________________________________________
Are you currently under the care of a physician? No ____ Yes ____
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? ________________________________________
Do you have any allergies? ______________________________________________________
Disclaimer: I understand that Reiki is a simple, gentle, non-invasive 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 compliment any medical or psychological care I may be receiving, and 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. I acknowledge that this is not a massage and is not a licensed massage therapy. I am receiving Reiki.
Signed: _________________________________________ Date: __________________
Privacy Notice: no information about any client will be discussed or shared with any 3rd party without written consent of the client or parent/guardian if the client is under 18.
