Reiki Intake Form

    Date

    First Name

    Last Name

    Your preferred name (Required)

    Date of Birth

    Address

    Telephone

    Email Address (required)

    Would you like to receive updates via email?
    YesNo

    Primary Concerns – Please list 3 concerns and give them a level from 1-10. 1 being hardly notice symptoms and 10 being symptoms are unbearable:

    Please list medications/remedies/supplements and reasons for taking:

    Please list any significant accidents/injuries:

    Please tick any conditions that apply:
    CANCERVARICOSE VEINSALLERGIESHEART DISEASEH/L BLOOD PRESSURESURGERYDIABETESPARALYSISGENETIC DISORDERSSTROKETMJ DYSFUNCTIONPHOBIASEPILEPSYARTHRITIS

    Please tick any symptoms that you experience:

    OTHER (please state)

    If you smoke, how many times a day to you smoke?

    Please tick any areas you would like to see an improvement in:
    NEGATIVE SELF-TALK, SELF-SABOTAGEABILITY TO REACH IDEAL WEIGHTABILITY TO TAKE ACTIONINCREASE LEARNING ABILITYBELIEF IN ABILITY TO ACHIEVE GOALSPERSONAL MAGNETISMBENEFICIAL, RELATIONSHIPSSTRENGTHEN MEMORY/CONCENTRATIONPROSPERITY (ATTRACT WHAT YOU CHOOSE)ABILITY TO RELAXABILITY TO USE DREAMS AS MENTAL TOOL FOR PROBLEM SOLVINGBREAKING OLD HABITSATTITUDE AND SKILLS AT WORKRELEASE NEGATIVE EVENTSSELF-ESTEEMABILITY TO ALIGN BODY/MIND FOR SELF-HEALINGYOUTHFUL VITALITYELIMINATE PROCRASTINATION

    Below, please describe what you would like to accomplish with these treatments:

    I consent to treatment for myself (or my minor child), and understand that the services provided by the practitioner Rachel Farnsworth is intended to enhance relaxation and increase communication within my body.

    I understand that these services are not a substitute for medical treatment or medications.I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan.

    I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that I may experience ‘healing reactions’ during the 24 to 48 hours following the services provided.

    I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone
    without my written permission. I do, however, give the practitioner consent to use my case history and results without using my name. I understand that only the practitioner Rachel Farnsworth will have access to information in my file to enhance my healing.

    I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless both the practitioner Rachel Farnsworth and the facility/location where the services are provided.

    I agree to the terms and conditions set out by this consent form and certify that the above information is true and correct. I agree to pay for distance sessions, should I request them.