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Reiki Intake form

First name*

Last name*

Email*

Phone*

I have received Reiki in the past

yes

no

What are you looking to receive in your Reiki treatment?

Is light touch ok?

Yes

No

Any sensitivity to scents or sounds*

Yes

No

Please describe*

Check any that apply:

Stress/Anxiety

Insomnia/trouble sleeping

Pain

I have a medical condition*

Please describe medical condition/treatment.*

Anything else I should know?

Signature*

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Reiki is a gentle non-invasive treatment. Information shared is confidential.

Specific outcomes/results are not guaranteed.

I have read and consent to treatment from HLHS.

For appointments
please call or text
541.350.5252

Anna Marie Casey

Disclaimer

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