Reiki Client Information Form Please provide your details, session history, and consent to the Reiki disclaimer and privacy notice. Full Name (Please Print)* First NameLast Name Phone (home)* Please enter a valid phone number.Format: (000) 000-0000. Cell phone or evening* Please enter a valid phone number.Format: (000) 000-0000. Address* City, State, Zip* Email (optional) example@example.com Emergency Contact* How did you hear about us?* Have you ever had a Reiki session before?* YesNo If yes, when was your last session? -Month -DayYearDate Number of previous sessions Do you have a particular area of concern? Are you sensitive to perfumes or fragrances? YesNo Are you sensitive to touch? YesNo DisclaimerI understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.Privacy Notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18. Signed (type full name)* Date* -Month -DayYearDate I agree to the statements above.* I agree SubmitSubmit Should be Empty: