Intake Form New Client | Prescott Reiki & Nutriton

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Birthday

Month

Day

Year

Have you had a Reiki treatment before? If so, when?

Do you have a pacemaker?

Are you diabetic?

Reiki can support your overall wellbeing on the physical, mental, emotional & spiritual levels. Please share anything you would like me to be aware of before your session. Your answers help me understand where you would most like support so we can spend more of your appointment time on your Reiki treatment.

We are together for an hour and a half and I leave 15 minutes for after your treatment for you to share what occured for you and I will share any impressions that I have. Being succinct in the beginning of our time together will maximize your Reiki treatment time. Thank you!

What would you like support with today? Check all that apply:

Physical — pain, discomfort, fatigue, sleep, digestive issues, injury, etc.

Mental — stress, overwhelm, racing thoughts, difficulty focusing, etc.

Emotional — anxiety, grief, sadness, anger, emotional stress, etc.

Trauma — past or recent experiences that may still be affecting you

Spiritual — feeling disconnected, stuck, or seeking greater balance

Relaxation & general well-being

Please briefly explain anything you have checked above.

What is your goal for today?

*** Backways is a fragrance free facility ~ please note ~ Thank you

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor 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 see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or 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 sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

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Thank you for your time today ~ I appreciate you & look forward to seeing you!

Have a great day!

Jion

Prescott Reiki & Nutrition

PRESCOTT REIKI & NUTRITION