Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Emergency Contact Only used in the unlikely event of an emergency. First Name Last Name Phone (###) ### #### Current Medications & Supplements Are you currently pregnant? Yes No Relationship status & children Have you ever had a Reiki session before? Yes No What are your areas of concern? Or what is brining you to this Reiki session? What are your intentions for this session? Are you sensitive to fragrances? Essential oils, palo santo, sage, etc? Do you have any allergies? Is there anything else you wish for me to know before our session? How did you find my website? Thank you!
