Consent Form | Kitty's Reiki

Kitty's Reiki Intake & Consent Form

Client's Name

First name

Last name

Preferred name (If you have one)

Preferred Pronouns

Birthday

Month

Day

Year

Contact Info

Phone Number

How did you hear about us?

Address

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Medical History

Have You Received a Reiki Session Before?

Yes

Do you have any medications that you are currently taking? If so please list them and their dosages

Have you had surgery recently? If so when and what for?

Do you or have you ever suffered from seizures of any sort? If yes please elaborate

Do you have any medical conditions or concerns that you believe may affect your ability to receive Reiki treatment? (e.g. heart conditions, epilepsy, brain injuries, pregnancy, etc..)

If you have any additional underlying conditions or concerns that you wish to disclose to the practitioner, please list them here