Client Intake & Consent Form

Please complete the following form before your first Reiki or sound healing session. The information you provide helps me understand your needs, preferences, and any health or personal considerations that may be important for creating a comfortable and supportive experience.

First name*

Last name*

Email*

Phone*

Address*

Select any that may apply to you*

I am currently pregnant

I am recovering from an illness or injury

I have chronic pain or ongoing physical discomfort

I have an area of pain, tenderness, or sensitivity that I would like you to be aware of

Recent surgery

Surgical implants

Pacemaker or other implanted electronic device

Joint replacement or other orthopedic implant

Other medical device or implant

I am experiencing emotional and/or mental distress

None of the above

If applicable, please provide any information you feel is relevant to your session:

Is there anything regarding your current mental or emotional well-being that you would like me to be aware of before your session?

Are you sensitive to sound, vibration, or loud/high-pitched sounds?*

Yes

Not Sure

Do you understand that you may ask questions, request changes, pause, or end your session at any time?*

Yes

Do you understand that Reiki and sound healing are complementary wellness services and are not a substitute for medical or mental health care?*

Yes

Do you voluntarily consent to receive Reiki and/or sound healing services?*

Yes

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