Reiki Intake Form

New Reiki Clients: Please fill out our electronic intake form prior to your appointment and click submit when complete. Thank you!

BODY RHYTHMS MASSAGE

Reiki Intake Form

Full Name

Address/City/State/Zip Code

Cell Phone

Date of Birth

Social Situation: (Marital Status, Family, Support)

Spiritual Practice/Belief: Meditation, Prayer, etc.)

Emergency Contact Phone

Reason for visit:

Key Medical History:

Medications/Supplements:

Stress/Areas of Concern:

Relaxation/Self Care:

Mutual Goals:

Please list any physical, mental, emotional, or spiritual issues you would like me to know about prior to treatment:

The principle behind Reiki is that our bodies are electromagnetic and energetic in nature and this energy can be influenced in a healthy, positive way to balance the mind, body, and spirit. This natural healing energy flows in a powerful and concentrated form through the hands of the Reiki practitioner and enters the body of the receiver.

Through the spiritual healing art of Reiki, Lisa helps clients relax, clear negative energy, and move positive energy throughout the body for balance and clarity. A compliment to traditional medicine and other healing techniques.

I, the undersigned, understand that the Reiki session is given for the purpose of stress reduction and relaxation. I understand that a Reiki session is not a substitute for a medical or psychological diagnosis and/or treatment. Reiki Practitioners will not interfere with the treatment of a Licensed Medical Professional. It is recommended that I see a Licensed Physician or Licensed Health Care Professional for any physical or psychological ailments I may have. I hereby give my permission for Lisa Dempsey to give a hands-on Reiki Treatment.

Your Signature

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