Reiki Intake Form – Loving More Perfectly | Reiki Master Teacher ◦ Vaughan ◦ Toronto

City, Province/Stage, Postal Code/Zip

Emergency Contact (name, relationship, phone)

Are you currently under the care of a physician?

yes no

If yes, please provide physicians name

How did you hear about us?

Have you had a reiki session before?

yes no

If yes, when was your last session?

Please describe any mental, emotional, physical or spiritual imbalances you are looking to heal with Reiki:

Are you okay with touch?

Yes, I'm comfortable No touch is preferred

Are you sensitive to perfume or fragrance?

Yes No

Please read below statement and check to accept:

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.

Check to accept appointment change/cancellation policy:

I acknowledge that I understand the cancellation policy, which states that cancellations or rescheduling must be made at least 24 hours in advance. If an appointment is canceled or rescheduled with less than 24 hours' notice, a $50 cancellation fee will apply.

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