Energy Therapy Client Information Form

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Energy Therapy Client Information Form
Name_____________________________________________________________
Home Phone_______________________ Cell Phone_________________________
Home Address______________________________________________________
City, State & Zip____________________________________________________
Email Address ______________________________________________________
Person to contact in an emergency_______________________________________
Phone______________________________ Relationship_____________________
Have you ever had a Reiki or IET® session before? ____Yes
____No
What would you like to accomplish with this Energy Therapy session?
___Relaxation ___Stress Reduction ___Pain Reduction ___Other – please explain
_________________________________________________________________
_________________________________________________________________
Would you like to state an intention for yourself with this Energy Therapy session?
_________________________________________________________________
Client Signature____________________________________ Date_____________

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