Please fill in the Reiki Client Information Form below:

Phone (home):
Phone (cell or evening):
Emergency Contact (Name & Phone Number):*
Current Medications and Dosage
Are you currently under the care of a physician?
If Yes, please indicate the physician's name:
How did you hear about us?
Have you ever had a Reiki session before?
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?
Are you sensitive to touch?

I understand that Reiki 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 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.