Client Intake Form Client Name(Required) First Last Address (including city and country)(Required) Cell Phone Number(Required)Email(Required) Occupation / Job ex - software engineer, teacher etc.AgeEmergency Contact: (Name/Relationship) Emergency Contact's Phone Number(Required)How did you hear about Healing Insightfully?(Required)Ex. Yelp, Google, Internet search, referral + name of the person who referred you.How would you like your session to be guided?(Required) I’m seeking deep rest and relaxation (Reiki-focused) I’m looking for support with stress, emotions, or patterns (somatic-focused) I’m not sure — I’d like guidance in the session Are you sensitive to perfumes and fragrances? Yes No Are you sensitive to touch? Yes No Have you ever had a Reiki session before?(Required) Yes No When was your last Reiki session?Never had Reiki beforeLess than a month agoBetween 1 - 6 months ago6 months to a year agoWay over a year agoDon't rememberNumber of previous Reiki sessions you have had and how was your experience?(Optional question)Do you have any mental health conditions?Do you have a particular intention or area of concern to address during your Reiki session?(Required)Attach a photo for Distant phone session (optional)Accepted file types: jpg, png, pdf, Max. file size: 256 MB.Consent(Required) 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, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. 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.E-signature (Full Name)(Required) Date MM slash DD slash YYYY CAPTCHA
