Client Intake Form for Reiki,
Energy Healing Therapy
Client Information
First Name
Last Name
Date of Birth
Gender
Phone
Street Address
City/Suburb
State/Province
Zip/Postal Code
Emergency Contact
First Name
Last Name
Phone
Relationship
Health History
Do you have any current medical conditions or diagnoses?
If yes, please specify:
Are you currently under the care of a physician or healthcare provider?
If yes, please provide details:
Are you taking any medications or supplements?
If yes, please list:
Have you had any recent surgeries or hospitalizations?
If yes, please provide details:
Do you have any allergies or sensitivities?
If yes, please specify:
Do you have any physical limitations or injuries that may affect your ability to lie down or sit comfortably during the session?
If yes, please describe:
Are you pregnant or trying to conceive?
Yes
No
Not Applicable
Do you have a history of mental health conditions (e.g., anxiety, depression, PTSD)?
If yes, please describe:
Energy Healing Experience
Have you ever received Reiki or energy healing before?
If yes, please describe your experience:
What are your goals for this session? (Check all that apply)
Stress reduction
Pain relief
Emotional healing
Spiritual growth
Improved sleep
Enhanced energy
Other:
Do you have any preferences for the type of energy healing therapy? (See list below)
Reiki
Chakra Balancing
Crystal Healing
Sound Healing
Pranic Healing
Shamanic Healing
Other:
Therapies Offered
Please review the following therapies and indicate your interest or concerns:
Program | Interested? | Questions/Concerns | ||
|---|---|---|---|---|
A | B | C | ||
1 | Reiki: A Japanese energy healing technique that promotes relaxation, stress reduction, and emotional balance | |||
2 | Chakra Balancing: Focuses on aligning and clearing the body's energy centers (chakras) to improve physical, emotional, and spiritual well-being. | |||
3 | Crystal Healing: Uses crystals and gemstones to amplify energy, clear blockages, and promote healing. | |||
4 | Sound Healing: Utilizes sound vibrations (e.g., singing bowls, tuning forks) to restore harmony and balance. | |||
5 | Pranic Healing: A no-touch energy healing technique that cleanses and energizes the body's energy field. | |||
6 | Shamanic Healing: Incorporates traditional shamanic practices, such as soul retrieval or energy extraction, to address spiritual and emotional imbalances. |
Suitability and Preferences
Do you have any fears or concerns about energy healing?
If yes, please describe:
Are you comfortable with light touch or no-touch therapy?
Light Touch
No Touch
No Preference
Do you have any spiritual or religious beliefs that may influence your healing experience?
If yes, please describe:
Is there anything else you would like your practitioner to know before the session?
Consent and Agreement
I understand that Reiki and energy healing are complementary therapies and are not a substitute for medical or psychological treatment.
I consent to receive energy healing therapy and understand that I can stop the session at any time if I feel uncomfortable.
I acknowledge that the practitioner will keep my information confidential unless required by law to disclose it.
I give permission for the practitioner to use light touch or no-touch techniques during the session.
Client Signature
Client Intake Form Insights
Client Intake Form Insights
Please remove this Client Intake Form Insights section before publishing.
Below is a detailed breakdown of the Client Intake Form, explaining the purpose and importance of each section, as well as how it contributes to creating a safe, personalized, and effective healing experience for the client.
1. Client Information
Purpose:
- To establish basic contact details and identify the client.
- To ensure the practitioner can reach the client if needed and contact an emergency contact in case of an unforeseen situation.
Why It Matters:
- Accurate contact information ensures smooth communication.
- An emergency contact is crucial in case the client experiences discomfort or a health issue during the session.
2. Health History
Purpose:
- To assess the client's physical and mental health status.
- To identify any contraindications or precautions needed for energy healing therapies.
Why It Matters:
- Certain medical conditions (e.g., epilepsy, heart conditions, pregnancy) may require adjustments to the therapy or avoidance of specific techniques.
- Medications or recent surgeries may affect the client's energy levels or sensitivity to energy work.
- Allergies or sensitivities (e.g., to essential oils, crystals, or sounds) must be noted to ensure safety.
- Physical limitations (e.g., injuries, mobility issues) help the practitioner tailor the session setup (e.g., using a chair instead of a massage table).
3. Energy Healing Experience
Purpose:
- To understand the client's familiarity with energy healing and their expectations for the session.
- To gauge their comfort level and preferences for specific therapies.
Why It Matters:
- Clients new to energy healing may need more explanation and reassurance, while experienced clients may have specific preferences or goals.
- Knowing the client's goals (e.g., stress reduction, emotional healing) allows the practitioner to focus the session on their needs.
4. Therapies Offered
Purpose:
- To provide the client with an overview of available therapies and allow them to choose what resonates with them.
- To address any questions or concerns the client may have about specific modalities.
Why It Matters:
- Different therapies (e.g., Reiki, chakra balancing, sound healing) work in unique ways, and clients may feel drawn to one over another.
- Addressing concerns upfront ensures the client feels comfortable and confident in their choice.
5. Suitability and Preferences
Purpose:
- To explore the client's comfort level with energy healing and identify any fears or reservations.
- To understand their preferences for touch, spiritual beliefs, or other factors that may influence the session.
Why It Matters:
- Some clients may have fears about energy work (e.g., "Will it conflict with my religious beliefs?" or "Will I feel out of control?"). Addressing these concerns builds trust.
- Preferences for light touch, no touch, or specific techniques ensure the session aligns with the client's comfort level.
- Spiritual or religious beliefs may influence the client's openness to certain practices (e.g., shamanic healing or chakra work).
6. Consent and Agreement
Purpose:
- To inform the client about the nature of energy healing and obtain their consent for treatment.
- To establish boundaries and ensure the client understands their rights during the session.
Why It Matters:
- Energy healing is a complementary therapy and not a substitute for medical treatment. Clarifying this avoids misunderstandings.
- Consent ensures the client feels empowered and in control of their experience.
- Confidentiality agreements build trust and professionalism.
7. Client Signature
Purpose:
- To formalize the client's agreement to the terms and conditions of the session.
Why It Matters:
- A signed form provides legal protection for both the client and the practitioner.
8. Practitioner Notes
Purpose:
- To allow the practitioner to document observations, client preferences, or specific concerns.
Why It Matters:
- Notes help the practitioner tailor future sessions and track progress over time.
Key Insights and Best Practices
- Personalization:
The form ensures the session is tailored to the client's unique needs, preferences, and health status.
For example, a client with anxiety may benefit more from gentle Reiki and sound healing, while someone with chronic pain may prefer chakra balancing and crystal healing. - Safety:
By identifying contraindications (e.g., pregnancy, epilepsy), the practitioner can avoid techniques that may not be suitable.
For instance, strong sound vibrations may not be appropriate for someone with a history of seizures. - Building Trust:
Asking about fears, preferences, and spiritual beliefs shows the client that their comfort and well-being are prioritized.
This fosters a sense of safety and openness, which is essential for effective energy healing. - Legal and Ethical Considerations:
The consent section ensures the client understands the scope of energy healing and their rights during the session.
Confidentiality agreements protect the client's privacy and uphold professional standards. - Client Empowerment:
By allowing clients to choose their preferred therapies and express their goals, the form empowers them to take an active role in their healing journey.
How to Use the Form Effectively
- Pre-Session Review:
Review the form before the session to familiarize yourself with the client's needs and preferences. - Open Communication:
Use the form as a starting point for a conversation with the client. Ask follow-up questions to clarify their responses. - Adaptability:
Be prepared to adjust the session based on the client's feedback and comfort level during the session. - Documentation:
Keep the form on file for future reference, especially if the client returns for additional sessions.
This detailed intake form not only ensures a professional and safe practice but also enhances the client's experience by making them feel heard, respected, and cared for. It sets the foundation for a trusting and effective therapeutic relationship.
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