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New Client Intake Form

Multi-line address
The following information will help me plan a safe & effective series of Reiki sessions for you.

Please answer the questions to the best of your knowledge.

Have you ever had a Reiki Session before?
Do you have difficulty lying on your front?
Yes
No
Do you have difficulty lying on your back?
Yes
No
What is your goal for today's Reiki session? Please check all that apply.
Please rate the stress level in your life (5 being the highest).
1
2
3
4
5
How do you think stress is affecting your health? (Please check all that apply.)
Are you experiencing tension, stiffness, pain, or other discomfort in your body?
Yes
No
Do you have allergies or sensitivities?
Yes
No
Please check any medical conditions you have.
Are you currently being treated by a medical provider for any diagnosed health condition?
Yes
No
Are you currently taking any medication?
Yes
No
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