Today's Date MM DD YYYY Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### What brings you here today? What are your goal(s) for our session? * This can include physical, mental, emotional and/or spiritual matters Is there any important information regarding your physical or psychological medical history? * Did you receive any kind of energy healing/therapy before? Is so, what kind and when? * Do you consume alcohol, drugs or tobacco? * Emergency Contact * Full Name and phone number Are you sensitive to smoke, perfume or fragrances? * Yes No Are you sensitive to touch? * Yes No Do you prefer a Hands-on or Hands-off approach in your treatment? * Hands - off Hands - on Please read carefully I understand that Energy Healing (including Reiki, Sound Healing and IEH (Intuitive Energy Healing), Crystal Healing, and other techniques) is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand Shayla M. Rose, as the Reiki Practitioner does not diagnose nor treat medical conditions. I understand Reiki does not take the place of medical care. I understand that Energy Healing can complement any medical and psychological care I may be receiving. 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 require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. Signed (Print) & Date Thank you and welcome to Reiki with Shayla M. Rose! Thank you! Reiki Intake Form
