Client Information Form

Name:Phone number:Day time or evening preferred?Address:Emergency contact and phone number:How did you hear about us?Have you ever had a Reiki/Energy Medicine session before?YesNoIf yes, what type of service have you received?Number of previous sessions:Do you have particular area of concern?Are you sensitive to perfumes or fragrances?Are you sensitive to touch?I understand that Reiki/Energy Medicine techniques are used for stress reduction and relaxation. I understand that Reiki/Energy Medicine 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/Energy Medicine 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/Energy Medicine 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.

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