
First Name
Last Name
Date of Birth
Gender
Phone
Street Address
City/Suburb
State/Province
Zip/Postal Code
First Name
Last Name
Phone
Relationship
Do you have any current medical conditions or diagnoses?
Are you currently under the care of a physician or healthcare provider?
Are you taking any medications or supplements?
Have you had any recent surgeries or hospitalizations?
Do you have any allergies or sensitivities?
Do you have any physical limitations or injuries that may affect your ability to lie down or sit comfortably during the session?
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)?
Have you ever received Reiki or energy healing before?
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:
Please review the following therapies and indicate your interest or concerns:
Program | Interested? | Questions/Concerns | |
|---|---|---|---|
Reiki: A Japanese energy healing technique that promotes relaxation, stress reduction, and emotional balance | |||
Chakra Balancing: Focuses on aligning and clearing the body's energy centers (chakras) to improve physical, emotional, and spiritual well-being. | |||
Crystal Healing: Uses crystals and gemstones to amplify energy, clear blockages, and promote healing. | |||
Sound Healing: Utilizes sound vibrations (e.g., singing bowls, tuning forks) to restore harmony and balance. | |||
Pranic Healing: A no-touch energy healing technique that cleanses and energizes the body's energy field. | |||
Shamanic Healing: Incorporates traditional shamanic practices, such as soul retrieval or energy extraction, to address spiritual and emotional imbalances. |
Do you have any fears or concerns about energy healing?
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?
Is there anything else you would like your practitioner to know before the session?
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
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:
Why It Matters:
2. Health History
Purpose:
Why It Matters:
3. Energy Healing Experience
Purpose:
Why It Matters:
4. Therapies Offered
Purpose:
Why It Matters:
5. Suitability and Preferences
Purpose:
Why It Matters:
6. Consent and Agreement
Purpose:
Why It Matters:
7. Client Signature
Purpose:
Why It Matters:
8. Practitioner Notes
Purpose:
Why It Matters:
Key Insights and Best Practices
How to Use the Form Effectively
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.