Reiki Consultation Form Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about us? * Recommendation Social Media Psyche Website The FIT Partnership Emergency Contact and Number * Are you under the care of a GP and/or healthcare professional? * Yes No Are you taking any medication? * Yes No Have you had an energy treatment before? Reiki Other treatment No How would you describe your energy levels? * Low Medium High How would you describe your stress levels? * Low Medium High Do you exercise? * Daily 3 - 4 times a week 1 - 2 times a week Never How would you describe your sleep pattern? * What do you do for relaxation? * Are you sensitive to perfumes or fragrances? * We will discuss and agree in advance potential use of any essential oils or room sprays Are you sensitive to touch? * During your treatment there will be gentle hand placement to appropriate body areas e.g. head, arms, chakras etc. If you are sensitive to touch and wish to experience a hands off treatment, please give details. What is the reason for your Reiki Therapy? * Physical health Emotional Health Mental / Spiritual health Relaxation / Stress reduction Client Declaration * 1. I declare the information that I have given is true and correct and that, as far as I am aware, I can receive the treatment with this therapist without any adverse effects. 2. I have been fully informed about the treatment and I am willing to proceed. 3. I understand that this is not a substitute for medical advice and/or treatment. I confirm I have read these statements carefully and agree to proceed with the Reiki treatment Thank you for completing the Reiki Consultation Form. Looking forward to seeing you for your treatment!Feel free to get in touch for any questions prior to your session.
