Name ____________________________________________ (Nickname)_______________________________

Address ___________________________________________________________________________________

City/State/Zip _______________________________________________________________________________

Email _____________________________________________________________________________________

Date of Birth _______________________________________________________________________________

Occupation _________________________________________________________________________________

Emergency Contact Name/Number ______________________________________________________________

1. Have you had a Reflexology treatment before? Yes / No If yes, date of last session? _________________

2. What were you being seen for? ______________________________________________________________

3. What was your experience like? _____________________________________________________________

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4. Do you have any difficulty lying on your back for the session? _____________________________________

If yes, please explain _________________________________________________________________________

5. Would you prefer a chair that keeps your body upright? Yes / No

6. Are you currently under medical supervision? Yes / No

7. Condition(s) being treated for _______________________________________________________________

8. Medicines presently taking & for what condition _________________________________________________

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9. What are your goals for today’s session? ______________________________________________________

10. Do you have any additional comments or questions before your Reiki session? ______________________

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Reflexology is a method of applying pressure to reflexes in the feet that correspond to each and every gland, organ and system of the body. There are over 7200 nerve endings (reflexes) in each foot. The theory of Reflexology is that the entire body can be mapped onto the feet. By applying pressure to these reflex points, a message travels through the nervous system to the brain which correspondingly sends a healing response to the stressed area of the body. Stimulation of these reflexes improves circulation, relieves stress, relaxes the body and effectively facilitates the natural healing process; thereby, revitalizing and enhancing your total health.

Please read and agree to the following before submitting your request:

Our services neither diagnose nor prescribe for disease conditions. All clients are encouraged to seek competent medical help when those services are deemed necessary. The client accepts total responsibility for his/her own health care and maintenance. Nothing said, typed, printed, or produced by us is intended or meant to diagnose, prescribe, treat a disease, or take the place of a licensed physician. This work is not medical treatment. It is a form of health maintenance utilizing the techniques and principles of reflexology. I understand that there may be some physiological responses that are sometimes related to the self-healing process such as: nausea, dizziness, diarrhea, muscle soreness, or depression, all of which may occur naturally as part of a cleansing process due to reflexology treatments. I further understand that reflexology may be helpful in the alleviation of pain from any suspected ailment(s) I may have had before the session. However alleviation of pain is not synonymous with "recovery" from any suspected dysfunction, and I will therefore refrain from any excessive activity that might cause further injury to myself during my healing process. By signing below, I acknowledge and fully agree with the above information.

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Signature of Reflexologist Signature of Client

Dated: _______________ Dated: _______________