Safe Space Healing
Client Intake Form for Reiki Treatment
PLEASE DO NOT WEAR PERFUME OR EXCESSIVE JEWELRY TO OUR SESSION. THANK YOU!
Name_____________________________ DOB___________ Referred By___________________
Address_____________________________ City__________________ State_______ Zip______
Are you sensitive to touch? _______________________________________________________
List any health issues, accidents or surgeries pertinent to this session:
Do you have difficulty lying on your back for an entire session? __________________________
What is the goal of this visit?
[ ] Relaxation [ ] More Energy [ ] Stress Reduction [ ] Trauma [ ] Pain Relief
[ ] Other___________________________________________________________
I truly hope you do not suffer from recurring thoughts of any of the emotions below, but if you do, would you circle those that apply please. It’s safe to answer, I used to have them too.
Pain - Anger - Fear - Depression - Anxiety - Other _________________________________________
What one emotion do you find yourself feeling the majority of your day? ______________
Do you practice having boundaries, self-care and self-compassion? ___________________
Do you have any questions or concerns before we begin?
Disclaimer: I agree that energy therapy such as Reiki, Healing Touch, Vibrational Sound Therapy or any other alternative modality is a beneficial adjunct to traditional medical approaches and is in no way intended to take the place of medicine or doctor’s visits. I understand that the practitioner is not a doctor and therefore does not diagnose maladies or prescribe medicines and I do not hold the practitioner or this facility responsible for my health issues or problems that arise during or after a session. The information that is exchanged during the session is educational in nature and to be used at my discretion. I understand that the practitioner is not a psychotherapist. Sessions are not intended to take the place of psychological counseling. I agree to inform the practitioner of any changes in my health status or any discomfort that arises during a session.
I understand that this is a professional and not personal agreement and to honor and respect that in all interactions. [ ] (initial)
I have the right to question my practitioner and/or request that the session be terminated. [ ] (initial)
By signing, I acknowledge the above as well as agreeing to Safe Space Healing’s cancellation policy below.
Client Signature _____________________________________Date_____________
Cancellation Policy: Clients may be charged in full for their appointment if they cancel in the same day of their appointment of if they fail to show up for their appointment. Cancellation fee will be waived if the therapist can fill the slot. Please cancel appointments a minimum of 24 hours in advance. Thank you!
Please return prior to your session. Email to