Reiki Intake Form

Thank you for booking your Reiki Session!

To help you prepare for the session, please complete this intake form.

Full Name

Preferred Phone Number

Address

Occupation

Emergency Contact Person

Relationship

Emergency Contact's Phone

How did you hear about us?

Have you ever had a Reiki session before?

Yes

If yes, for what purpose? (general wellness, stress reduction, etc.)

What do you hope to accomplish with this Reiki session?

Relaxation

Stress reduction

Pain reduction

Other

If other, please explain

What are your common areas of pain or tension?

List any specific areas you would like the practitioner to concentrate on during the session?

I hereby voluntarily request and consent to receive Reiki services from Wingspan Healing . I understand and acknowledge that no guarantees have been made to me as to the effect of such services. I further understand and acknowledge that in no way are these services meant to be construed by me as the diagnosis or treatment of disease, but rather as an aid to balancing my energy and to possibly improving my general wellness. I understand that prior to my first Reiki session, I will receive an oral explanation of and description of a Reiki session. I understand that I may refuse any and all services at any time during my first session or during any subsequent sessions. I understand that Wingspan Hearing Arts upholds the highest standards of care and professionalism and as an IARP® Registered Reiki Professional, abides by the IARP Code of Ethics. A copy is available for review. I understand that Reiki services provided by Wingspan Healing Arts are simply intended to enhance relaxation and to aid in stress reduction. I understand that Reiki is not a substitute for medical treatment or medications, and it is recommended that I concurrently work with my Doctor or Primary Caregiver for any condition I may have. I am advised that if I am sick, I should consult my Doctor. I am aware that my Reiki Practitioner does not diagnose illness or disease and does not prescribe medication. If I experience any discomfort during the session, I will immediately communicate that to the practitioner so the treatment can be adjusted.

Please re-type your full name here

Today's Date (MM/DD/YYYY)

Thank you for booking your Reiki Session!

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