Name ____________________________________________ (Nickname)_______________________________

Address ___________________________________________________________________________________

City/State/Zip _______________________________________________________________________________

Email _____________________________________________________________________________________

Date of Birth _______________________________________________________________________________

Occupation _________________________________________________________________________________

Emergency Contact Name/Number ______________________________________________________________

1. Have you had a Reiki 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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Reiki is the pure form of healing energy. A treatment feels like a wonderful glowing radiance that flows through you and surrounds you. Reiki treats the whole person including body, emotions, mind, and spirit and creates many beneficial effects including relaxation and feelings of peace, security, and well-being. Reiki is a simple, natural, and safe method of spiritual healing and self-improvement that everyone can use.

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, and we do not prescribe medications and/or substances. I understand that the Reiki session given involves a natural method of energy balancing for the purpose of stress reduction, relaxation, and healing. A Reiki professional will not interfere with the treatment of a licensed medical professional. I also understand that it is not massage therapy. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I have. By signing below, I acknowledge and fully agree with the above information.

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Signature of Reiki Master Signature of Client

Dated: _______________ Dated: _______________