Reiki Client Intake Form

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Reiki Client Intake Form: Practitioner Vanessa Kary
Name: (Please Print) ______________________________________________ Date: _________________________
Phone: ___________________________________ Email (Optional): ______________________________________
Address: ______________________________________________________________________________________
City/Town: ______________________________________ Postal Code: ___________________________________
Provide brief medical history. Particularly indicate significant data. (injuries, accidents, surgeries, seizures, etc.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you currently receiving other alternative treatments? (Please Circle)
Yes
No
If yes, please specify. (i.e. homeopathy, acupuncture, etc.) ______________________________________________
Have you had a Reiki Session before? (Please circle)
Yes
No
If yes, when was your last session? ____________________________ Number of previous sessions: ____________
Reiki involves a gentle, appropriate, hands-on technique. Are you ok with light touch? (Please Circle)
Yes
No
Do you have any difficulty lying on your front, back, or side? (Please Circle)
Yes
No
If yes, please explain: ____________________________________________________________________________
Do you find time to relax or meditate? If so, how often? ________________________________________________
Do you find time to exercise? If so, what type of exercise and how often? __________________________________
_____________________________________________________________________________________________
How many hours a night do you sleep? Is it restful? If not, please explain. __________________________________
_____________________________________________________________________________________________
Please rate your level of stress regarding work? (0 = none to 5 = Severe)
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5
Please rate your level of stress regarding family? (0 = none to 5 = Severe)
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5
Please rate your level of stress regarding health? (0 = none to 5 = Severe)
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Please rate your level of stress regarding financial? (0 = none to 5 = Severe)
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Do you have a particular area of concern you would like to focus on today? ________________________________
_____________________________________________________________________________________________
What would you like to get out of today’s Reiki session? ________________________________________________
_____________________________________________________________________________________________
Do you have any concerns you wish to discuss before the Reiki session begins? _____________________________
_____________________________________________________________________________________________
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