top of page
homeButtonLink
Home
About
Services
Gift Card
Contact
Log In
Reiki Client Intake Form
First name
*
Last name
*
Phone
*
Email
*
Birthday
*
Month
Day
Year
Emergency Contact Name
*
Emergency Contact Phone
*
1. What brings you in for a Reiki session today?
*
2. Have you ever received Reiki before? If yes, when and how was the experience?
*
3. Do you have any current physical concerns (e.g., pain, injuries, chronic conditions)?
*
4. Do you have any emotional or mental health concerns you'd like to share (e.g., stress, anxiety, grief)?
*
5. Do you have any sensitivities to scents, sounds, or touch I should be aware of?
*
6. Do you have any specific intentions or goals for this Reiki session?
*
7. Is there anything else you would like me to know before we begin?
Signature
*
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Submit
bottom of page