Energy Therapy Client Information Form printable pdf download

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_____________

Energy Therapy Client Information Form