Client Information Form

Please complete the form below and click the “submit” button when you are finished. It will only take a few minutes. Once you start, you won’t be able to “save” and come back to it later.

Alternatively, download and print the form by clicking here.

Name

First Name

Last Name

Mobile Phone

(###)

###

####

Home Phone

(###)

###

####

Which is best to reach you on?

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Marital Status

Age

Birthday

Occupation

Number of Children

Sex and Ages

Referral Source

Are you currently seeing a medical doctor for physical problems?

If so, What are you being treated for?

Are you currently taking any medication?

If so, what medications?

Are you pregnant?

If so, how far along are you?

# months

Any complications?

Do you have any physical complaints and symptoms?

If so, what are they?

(i.e. backache, joint pain, digestive issues)

What is your opinion of your emotional status?

(i.e. depression, anxiety, etc.)

Are you currently seeing a psychologist/psychiatrist/ social worker?

If so, for what reason?

Are you taking any psychotherapeutic medication?

Medication Name

What brings you to this session?

What do you hope to gain from this work?

Describe a scene in nature that relaxes you.

(i.e. a walk on the beach)

Patient Agreement (Required)

I understand that the Reiki/ Emotional Freedom Technique(EFT)/ Yoga session given is for the purpose of stress reduction and relaxation. I understand that a Reiki/ Emotional Freedom Technique(EFT)/ Yoga session is not a substitute for medical or psychological diagnosis and treatment. Reiki practitioners do not diagnose conditions, nor do they prescribe or perform medical treatments, nor substances, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician for any physical ailment I have. I understand that I must give 24-hour notice of appointment cancellation or I will be responsible for the full payment.

Yes