Intake Form - Create & Blossom

Patient Intake Form (#3)

First Name

Last Name

Phone no.

Date of Birth

Emergency 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.

Yes

I 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.

Yes

I 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.

Yes

Todays Date

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Hi! I’m Catherine