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.