Reiki Client Intake Form
Please complete prior to your session.

First Name *

Last Name *

Phone *

Email *

Emergency Contact *

How did you hear about me? *

Have you ever had a Reiki session before? *

Yes

If yes, when was your last session?

What brings you in for this session? *

Are there any medical conditions, injuries, surgeries, or health concerns I should be aware of before your session? *

What would you like to receive or reconnect with during this session? *

Acknowledgment & Consent

I understand that Reiki is a complementary wellness practice intended to support relaxation, energetic balance, grounding, and overall well-being. Reiki practitioners do not diagnose conditions, prescribe treatment, or replace licensed medical or mental health care.

I understand that experiences during and after Reiki sessions vary from person to person and results cannot be guaranteed.

I understand I may pause or end the session at any time.

Signature *

Clear

Date *