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Clarion Vitality - Reiki In-take Form

Please fill out the following form before your first session. We will go through the form together at your first session and you will have a chance to ask any questions if you have any.

Personal Information

Date of birth
Month
Day
Year

Emergency Contact Info

Health & Wellness Background

Are you currently under the care of a physician or specialist?
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
Do you have any implanted medical devices? (Check all that apply) *This question relates to the use of the PEMF mat during your treatment*
Are you currently pregnant or breastfeeding?
Do you have any of the following conditions? *This question relates to the use of the PEMF mat during your treatment*

Lifestyle and Stress

How would you rate your current stress levels?
How would you describe your current activity level?
Please check any areas you feel drawn to share — this is not a diagnosis.

Reiki Experience

Have you received Reiki before?
For your comfort, please indicate your preferences. Tick all that apply

Consent & Agreement

I understand that Reiki & PEMF therapy is a non‑medical wellness modality and is not a substitute for medical diagnosis or treatment. I agree to inform my practitioner of any changes in my health status. I acknowledge that results vary and no specific outcomes are guaranteed.


Consent


I voluntarily consent to receive Reiki energy work and acknowledge that I have shared information honestly to the best of my ability.

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