Patient Intake Form (#3)First NameLast NameEmailPhone no.Date of BirthEmergency Contact:Have You Ever Had a Reiki Session Before? If yes, when was your last session?Do you have a particular issue or concern that you are seeking help for? Are You Sensitive to Perfumes/Fragrances? Are You Sensitive to Touch?I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. YesI understand that Reiki practitioners do not diagnose, nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I seek a licensed physician or licensed health care provider for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. YesI also understand that the body has the ability to heal itself, and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. YesTodays Date Type Your Name Below To Sign This DocumentText InputSubmit Form