Name *
Date of Birth *
Date of Birth
Address *
Phone *
Have you ever had a Reiki session before? *
Are you sensitive to perfumes or fragrances? *
Are you sensitive to touch? *
I 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 healthcare professional for any physical or psychological ailment I may have. I understand that Reiki 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 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.
Stress Level: Pain Level: Quality of Life: