Initiate Your Wellness Journey Personal InformationName:(Required) Birthday: Month Day Year Address: Street Address Suburb State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Post Code Home Phone:Mobile:(Required)Email:(Required) Ok to Email Promos? Yes No Occupation: Status: F/T P/T Casual Emergency Contact Name: Relationship to You: Contact Phone:Healing InformationIf at any time during the session, you fill unwell or uneasy, please advise your healer. You're welcome to provide insights/experiences during the session, or you can advise upon the closure of the session.Have You Ever Had Energy Healing or Reiki Performed Before? Yes No If Yes, How Long Ago and What Was the Outcome? Have you ever had any other holistic or natural healing performed before? Yes No If Yes, What Was It, and How Long Ago and What Was the Outcome? What are your goals for this healing session? Tick all that apply:Physical Relief Yes No If Yes, Please Explain: Emotional Relief Yes No If Yes, Please Explain: Spiritual Relief Yes No If Yes, Please Explain: If applicable, mark the areas of concern on the chart below: Client AcknowledgmentsBy signing the below, you agree you have completed this form as honestly and completely as possible, and will advise if anything changes at any time; you understand energy healing is a natural, non-invasive modality to help bolster your own ability to heal and should not replace urgent or essential medical treatment by a medical practitioner.Client's Signature:Date: Month Day Year
