New Client Intake Form (v2)
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Additional Questions
Are you currently under the care of your Family Physician or a Specialist?
Are you taking any medications for medical concerns or recent surgeries? List Medications.
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Are you currently managing any chronic pain or areas of discomfort? If yes, please elaborate.
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Do you have any known allergies (specifically to essential oils, incense, or sage)? If yes, please share the specifics.
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Are you pregnant?
Yes
No
Have you experienced Reiki before?
Yes
No
What is your primary goal for your Reiki session (for example: stress reduction, emotional release, physical pain relief, general relaxation, energy balance, etc.)
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On a scale of 1-10, what is your current stress level?
1
2
3
4
5
6
7
8
9
10
Are there any specific areas of your body where you feel tension or "stuck" energy?
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The Reiki method I use is traditionally a close-hovering of the hands over the body method, however there may be occasional light touch. Do you consent to light physical touch on the head, shoulders, knees, or feet, if it would best serve the treatment?
Yes, I am comfortable with light touch.
No, I prefer only the close-hovering hands method. No light touch.
The session is meant to provide as much comfort as possible. For your blanket option which would you prefer?
Sheet
Comforter
Weighted blanket
Would you like a bolster for support?
Yes, bolster at knees.
Yes, bolster at feet.
Yes, bolster for neck and back support.
Yes, bolster for neck and back support and at knees.
No bolster (NOTE: a head pillow is provided along with knee or feet support, or when no bolster is requested, and can be easily removed as needed before or during session).
Would you like an eye mask?
Yes
No
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