New Client Intake - Reiki

First and Last Name

Address

Email

Yes, subscribe me to your newsletter.

Phone

Birthday

How did you hear about Spirit Springs Holistic Healing?

Have you had Reiki or other healing treatments before? If yes, what kind and when?

What is your intention for our session today?

What do you hope to gain from this experience

Reiki involved gentle, light touch but can also be performed above the body. Are you ok with light, hands-on touch?

Yes

No

Do you have difficulty lying on your back for the duration of the session?

Yes

No

Please check all tools that you are comfortable with me using during the session. I may use one or several of the options you select.

Please rate your stress levels 0=Low 5=Highest

Overall:

Work/Career/School:

Family/Relationships

Health

Financial/Security:

Any additional info you would like to share with me at this time?

Consent to services.

Please check each item confirming that you are consenting to each.

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, prescribe medications, or perform medical treatment.

I understand that Reiki does not take the place of medical or psychological care, but that it can complement any medical or psychological care I am already receiving.

I understand that the body has the ability to heal itself and that complete relaxation is beneficial for that process.

I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed for the body to heal itself.

I understand that this is a hands-on therapy and I consent to the therapeutic session.

I can stop the session at any time for any reason. (In the event of a stopped or interrupted session, refund will be issued on a case-by-case basis)

I release the practitioner and/or Spirit Springs Holistic Healing, LLC from any and all liability related to this experience.

Each session (from intake to completion) will be approximately 60 minutes. The cost for the session is $100 and payment shall be made prior to beginning. Cash, Venmo, or Zelle accepted and payment must be made in full prior to the start of the session.

Signature: By signing this intake, I agree to all terms and am consenting to services