Awareness

B K.I.S.S. Be Kind-hearted Be Inspired Be Strong Be Serene

Intake and Consent Form for Reiki

* Indicates required field

Name *

First

Last

Best Phone # To Get In Touch With You *

Date *

Email *

Best time to be reached *

what is the biggest problem or challenge you are facing in your life? *

What causes you the most pain physically or emotionally? *

How long have you been challenged? *

What has this issue cost you? (relationships, family, occupation, spiritually or income) *

Do you have the following feelings? *

Overwhelm Frustration Stress Anxiety Fear Depression Lost

What other kinds of personal help, therapy, or growth have you invested in? *

How do you cope with your feelings? (drinking, food, numbing, other peoples problems, shopping, yelling, ect.) *

Is there anything else you would like to share? *

Are you looking for (check all that apply) *

Stress Relief (Anxiety) Pain Relief Relaxation Healing old wounds or trauma Healing from past / current relationships Spiritual Growth

Other *

What specific emotional issues would you like to improve or heal? *

Are you currently seeing other health practitioners? Explain *

Occupation *

What is your household income? *

Less than $10,000 $10,001 - $25,000 $25,001 - $40,000 $40,001 - $70,000 $70,001 - $100,000 Greater than $100,000 Prefer not to say

Submit

GET YOUR 5 FREE MEDITATIONS AND LEARN TO HEAL YOURSELF NOW.

609.270.4898

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