Reiki Client Information form

Reiki Client Information Form

Reiki Client Information Form

1). Name:(Please Print)
2). Phone(home/cell)
3). Address:
4). City, State, zip:
5). Email:
6). Emergency Contact:
7). Current medications and dosage:
8). Are you currently under the care of a physician?
9). If yes, physician's name:
10). How did you hear about Reiki in the Prairie LLC?
11). Have you ever had a Reiki session?
12). If yes, when was your last session?
13). Number of previous sessions?
14.) Do you have a particular concern?

I understand that Reiki is a simple, gentle, hands-on and hands-off 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 aliment 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 requires multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

Signed: Date:

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