REIKI FORM

REIKI INFORMATION FORM

NAME

First Name

Last Name

PHONE

(###)

###

####

E-MAIL

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

EMERGENCY CONTACT

First Name

Last Name

HAVE YOU EVER EXPERIENCED REIKI BEFORE?

IF YES, WHEN WAS YOUR LAST SESSION?

DO YOU HAVE A PARTICULAR AREA OF CONCERN?

ARE YOU SENSITIVE TO TOUCH?

WHAT DO YOU HOPE TO GET OUT OF YOUR REIKI SESSION?

ACKNOWLEDGEMENT

I understand that Reiki Therapy 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 compliment 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 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.

ACKNOWLEDGEMENT

I ACCEPT