INTUITIVE ENERGY HEALINGPlease fill in the following form ahead of treatment. Name * First Name Last Name Email * Phone * Country (###) ### #### Emergency Contact * Country (###) ### #### Date of Birth * MM DD YYYY How did you hear about me? Reasons for coming? Have you had any energy healing before - If so what and when was our last session? * Do you have a particular area of concern? Are your feet sensitive to touch? * No Yes Are you sensitive to fragrances? * No Yes Do you have difficulty lying on your back for the entire session? * No Yes Are you sensitive to touch during a session? * *Please indicate if you prefer a hands off treatment. No Yes MEDICAL HISTORY * Do you suffer with any of the following medical conditions? Allergies Illnesses Asthma Operations Diabetes Blood pressure Drugs/ Alcohol None of the above Are you pregnant? No Yes Are you currently under the care of a physician? * No Yes Are you on any medication? No Yes Client consent: * 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. I understand that Reiki does not take the place of medical or psychological care. 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. I understand Signed * (If client is a minor a parent or guardian must sign) First Name Last Name Date * MM DD YYYY Thank you!
