First Time Clients Information Form

If you are a first time customer then please fill out the form below. We will keep it on file for future visits.

Name

Phone

Address

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?

Yes No

I understand that Reiki is a simple, gentle, 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 complement 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 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.

Sign with finger on mobile or mouse on computer. Click X to clear and redo signature until you are happy with it.

Signature

Date

Privacy Notice:

No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

Client Information Form

Privacy Notice: