top of page

Clarion Vitality - Reiki In-take Form

Please fill out the following form.

Personal Information

Date of birth
Month
Day
Year

Emergency Contact Info

Health & Wellness Background

Are you currently under the care of a physician?
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes
Are you currently pregnant or breastfeeding?
Do you have a pacemaker or any kind of defibrillator?
Do you have any metal plates?
Do you experience any of the following? (check all that apply)

Lifestyle and Stress

How would you rate your current stress levels?
Do you practice meditation, yoga, or other relaxation techniques?

Reiki Experience

Have you received Reiki before?
What are your goals for today's session?

Consent & Agreement

I understand that Reiki is a form of energy healing and is not a substitute for medical treatment. Reiki practitioners do not diagnose conditions, prescribe medications, or interfere with medical care. I agree to take full responsibility for my health and well-being.

bottom of page