Name of person receiving Reiki *

First Name

Last Name

Name of parent/guardian if recipient is a minor

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency contact *

First Name

Last Name

Phone *

(###)

###

####

Have you had Reiki before? *

Yes

No

What do you hope to accomplish with your Reiki sessions? *

Relaxation

Stress reduction

Pain management

Other

Do you take any medications or supplements regularly?

Yes

No

Health complaints *

Arthritis

Asthma

Back pain

Bleeding

Circulatory problems

Diabetes

Epilepsy or seizures

Frequent headaches

Heart ailment

Joint swelling

Fibromyalgia

Skin disorders/rashes

Allergies

Infectious condition

Physical pain

Tension or soreness

Recent injury or surgery

Low blood pressure

High blood pressure

Signature *

First Name

Last Name

Date *

MM

DD

YYYY

Signature of parent/guardian

First Name

Last Name

Date

MM

DD

YYYY