Reiki Intake Form

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About You

First Name

Last Name

Email

Phone (optional)

Date of Birth

Session Type

How did you hear about us?

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Physical Health & Medical History

Do you have any current medical conditions or diagnoses?

Yes

No

Prefer not to say

If yes, please describe

Are you currently pregnant?

Yes

No

N/A

Are you currently taking any medications?

Yes

No

If yes, which medications?

Do you have any physical pain or discomfort right now?

Yes

No

If yes, please describe the area and sensation

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Emotional & Mental Wellbeing

How would you describe your current emotional state?

Are you currently experiencing or have you experienced any of the following?

Anything else you'd like to share about how you're feeling?

Everything shared here is held with care and confidentiality.

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Lifestyle & Daily Habits

How would you describe your sleep quality lately?

Great

Okay

Poor

Very poor

How is your relationship with food and nourishment?

Do you exercise or move your body regularly?

Daily

A few times a week

Rarely

Not at all

Do you spend time outdoors or in nature?

Daily

Sometimes

Rarely

How would you describe your social support?

Strong & nourishing

Limited

Draining

Isolated

Any other lifestyle factors you'd like to mention?

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Spiritual & Energy Intentions

Have you experienced Reiki before?

Yes

No, this is my first time

What are you hoping to receive from this session?

Set your intention for today's session

There are no right or wrong answers. Trust what arises.

Do you have any spiritual or energy practices?

Anything else you'd like me to know before our session?

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Consent & Agreement

I understand that Reiki is a complementary practice and does not replace professional medical or mental health care. *

I consent to receiving a Reiki session and agree that my information will be kept confidential. *

I agree to receive occasional session reminders or wellness tips by email. (Optional)

Full Name (as signature)

Date