Reiki & Energy Healing Therapy
Client Intake Form

Image of a person with hands in a healing position, symbolizing Reiki therapy.

Client Information

First Name

Last Name


Date of Birth

Gender


Phone

Email

Street Address

City/Suburb

State/Province


Zip/Postal Code

Emergency Contact

First Name

Last Name


Phone

Relationship

Medical History

Please list any current medical conditions:

Please list any past medical conditions:

Are you currently taking any medications?

Do you have any allergies?

Have you had any recent surgeries or injuries?

Are you currently under the care of a physician or other healthcare professional?

Are you pregnant or breastfeeding?

Do you have a pacemaker or other implanted medical device?

Do you have a history of seizures?

Do you have any metal implants?

Lifestyle and Well-being

Describe your general health and well-being:

How would you rate your stress levels (1-10, 1 being low, 10 being high)?

How would you rate your sleep quality? (1-10, 1 being Extremely Dissatisfied, 10 being Extremely Satisfied)?

Do you experience any chronic pain?

Do you experience any anxiety or depression?

Do you regularly engage in any form of exercise or relaxation techniques?

Purpose of Visit and Goals

What are your primary reasons for seeking Reiki or energy healing therapy?

What specific issues or concerns would you like to address?

What are your goals for this session and future sessions?

Have you received Reiki or other energy healing before?

What are your expectations from this session?

Therapy Options

Suitability Questions for Specific Therapies

Chakra Balancing

Are you comfortable with the practitioner working with your energy centers?

Do you have any questions or concerns about chakra balancing?

Crystal Healing

Do you have any sensitivities to specific stones or metals?

Do you have any concerns regarding the use of crystals on or near your body?

Sound Healing

Do you have any hearing sensitivities or conditions (e.g., tinnitus, hyperacusis)?

Do you have a history of seizures triggered by sound or light?

Do you have any concerns regarding vibrational frequencies?

Aura Cleansing

Do you have any mental health conditions that make you sensitive to energy work?

Do you have any concerns about energetic shifts?

Guided Meditation

Do you have any history of trauma or PTSD that may be triggered by guided meditation?

Are you comfortable with guided imagery and relaxation techniques?

Distance Healing

Do you understand that distance healing is a complementary therapy and not a replacement for medical treatment?

Do you understand the process of distance healing?

Informed Consent

I understand that Reiki and energy healing therapies are complementary therapies and are not a substitute for conventional medical treatment.

I understand that the practitioner will maintain confidentiality regarding my personal information, except as required by law.

I have accurately provided my medical history and other relevant information.

I have had the opportunity to ask questions and have received satisfactory answers.

I consent to receive the therapies indicated above.

Client Signature

Client Intake Form Insights

Please remove this Client Intake Form Insights section before publishing.


Let's dissect this Reiki and Energy Healing Therapy Client Intake Form to understand its detailed insights and purpose:


1. Client Information (Basic Data Collection):


Purpose: Establishes a foundational record of the client.

Insights:

  • Allows for easy contact and follow-up.
  • Provides demographic information (age, location) which can be relevant in some contexts.
  • Emergency contact information is crucial for safety.

2. Medical History (Safety and Contraindications):


Purpose: To identify potential contraindications or situations requiring caution.

Insights:

  • Current/Past Medical Conditions: Alerts the practitioner to conditions that may be affected by energy work or require modifications. Some conditions may need a doctors note before proceeding with energy work.
  • Medications/Allergies: Essential for avoiding adverse reactions. Certain medications can influence energy levels, and allergies must be considered when using essential oils or crystals.
  • Recent Surgeries/Injuries: Energy work can influence healing processes; awareness is vital.
  • Physician Care/Pregnancy/Pacemakers/Seizures/Metal Implants: These are critical safety questions. Energy work may be contraindicated or require special precautions in these cases.
  • This section is vital for risk mitigation.

3. Lifestyle and Well-being (Holistic Understanding):


Purpose: To gain a broader understanding of the client's overall health and lifestyle.

Insights:

  • General Health/Stress/Sleep: Provides insights into the client's baseline well-being and potential areas of imbalance.
  • Chronic Pain/Anxiety/Depression: Identifies specific areas of concern that energy work may address.
  • Exercise/Relaxation Techniques: Reveals the client's existing coping mechanisms and self-care practices.

4. Purpose of Visit and Goals (Client Intentions):


Purpose: To clarify the client's expectations and desired outcomes.

Insights:

  • Primary Reasons/Specific Issues: Helps the practitioner tailor the session to the client's needs.
  • Goals: Sets realistic expectations and provides a framework for evaluating progress.
  • Previous Experience: Allows the practitioner to gauge the client's familiarity with energy work and adjust their approach accordingly.
  • This section is very important for client satisfaction.

5. Therapy Options (Informed Choice):


Purpose: To allow the client to actively participate in choosing their therapy.

Insights:

  • Provides a clear overview of the available services.
  • Empowers the client to make informed decisions.
  • Helps the practitioner understand the client's preferences.

6. Suitability Questions for Specific Therapies (Targeted Safety):


Purpose: To address specific contraindications or sensitivities related to individual therapies.

Insights:

  • Crystal Healing: Addresses potential sensitivities to stones or metals.
  • Sound Healing: Addresses hearing sensitivities and potential seizure triggers.
  • Aura Cleansing: Addresses potential sensitivities in clients with mental health conditions.
  • Distance Healing: Ensures the client understands the nature of distance healing.
  • Chakra Balancing: Addresses any concerns about working with energy centers.
  • Guided Meditation: Addresses potential triggers for clients with trauma or PTSD.
  • This section minimizes risks associated with specific modalities.

7. Informed Consent (Legal and Ethical Protection):


Purpose: To ensure the client understands and agrees to the terms of the therapy.

Insights:

  • Confirms the client's understanding of the complementary nature of energy work.
  • Protects the practitioner from liability.
  • Reinforces confidentiality.
  • Ensures the client has provided accurate information.
  • Verifies that the client has had their questions answered.

8. Notes (Practitioner Documentation):


Purpose: To record observations, treatments, and client responses for future reference.

Insights:

  • Provides a record of the session for continuity of care.
  • Helps the practitioner track client progress.
  • Serves as a legal record.
  • Allows for better treatment plans for future sessions.

Overall Importance:

  • Client Safety: The form prioritizes client safety by gathering essential medical and lifestyle information.
  • Ethical Practice: Informed consent ensures transparency and empowers the client.
  • Effective Treatment: Understanding the client's needs and goals allows for tailored and effective therapy.
  • Legal Protection: Proper documentation protects the practitioner from potential liability.
  • Professionalism: A well-designed intake form demonstrates professionalism and attention to detail.

By carefully reviewing and analyzing the information provided in the intake form, practitioners can provide safe, effective, and client-centered Reiki and energy healing therapies.

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