ZenSpirit Questionare items with * are required. Your Name * Phone (Home) 555-555-5555 Format * Phone (Cell or Evening) Address * City, State, Zip * Your Email * Emergency Contact Current Medications and Dosages Are you currently under the care of a physician? yesno If yes, physician's name How did you hear about us? Have you ever had a Reiki session before? * yesno If yes, when was your last session? YYYY-MM-DD format (e.g. 2013-04-08). Number of previous sessions Do you have a particular area of concern? * Are you sensitive to perfumes or fragrances? yesnounsure Are you sensitive to touch? yesnounsure 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. Privacy Notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.