Reiki Client Intake Form

Please complete this form prior to your Reiki Session

Client intake form

First Name

Last Name

Date of Birth

Phone number

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Are you pregnant?

Yes

No

Have you received Reiki before?

Yes

No

If yes, when was the session and how was the experience?

What is your expectation for this Reiki session?

What would you like support with today?

List any medications, special conditions, treatments or medical history relevant.

Is there anything else we should know?

Preferred session type:

In-person

Distance Reiki

Are you comfortable with light touch during the session?

Yes

No (hands-off session)

All personal and health information shared during sessions will remain confidential unless required by law.

I understand

Reiki is a complementary therapy that supports relaxation and wellbeing. It does not diagnose, treat, or cure medical conditions and is not a substitute for professional medical care. I understand that Reiki practitioners do not diagnose medical conditions or prescribe medications. I confirm that I am responsible for my own health and will consult a licensed healthcare professional when necessary.

I consent to receiving Reiki from the practitioner.

May I contact you about future sessions or wellness events?

Yes

No

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Reiki and energy healing offered by Sacred Vessel Within are complementary wellness practices intended to support relaxation and well-being. They do not replace medical or psychological care.

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