HOME
Events
Free Meditations
FREE E-BOOK
SCHEDULE A CALL
Freedom Forever Community
Free FB Goup
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
Home Phone #
*
Date
*
Cell Phone #
*
Email
*
Do you consent to having our monthly newsletter sent to you?
*
YES
NO
Preferred contact method
*
Home
Cell
Email
Best time to be reached
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Gender
*
Male
Female
Emergency Contact
*
Relationship to client
*
Birth date (MM/DD/YY)
*
Emergency Phone
*
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
(Women Only) If pregnant, due date
*
Please list any special heath issues or requirements I need to know about (include health restrictions, allergies or other serious health concerns, and if required information on emergency care and your doctor)
*
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)
*
What other kinds of personal help, therapy, or growth have you invested in?
*
When you feel
*
OR
*
You
*
drink, eat, don't eat, shop, beat yourself up, shopping, etc.
Is there anything else you would like to share?
*
How did you hear about B KISS
*
Are you interested in learning more about Reiki
*
Yes
No
Maybe
Have you had a Reiki session before? If Yes when?
*
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 physical issues would you like to improve or heal?
*
What specific emotional issues would you like to improve or heal?
*
Are you currently seeing other health practitioners? Explain
*
Reiki is a hands-on holistic health treatment (or hands-off as requested) to encourage relaxation and healing. Reiki is practiced while the client is fully clothed, on a massage table. If at any time you feel discomfort, you may ask for the session to be stopped immediately (session can be resumed after problem is addressed). Sessions are most effective in silence, but sometimes it is necessary to voice what you are feeling, particularly for those unfamiliar with Reiki, in order to feel at ease. Please note, for serious health conditions please see a licensed medical practitioner. For such conditions Reiki is considered a complementary form of treatment.
required
*
Consent
By checking this box you understand the above statement in regards to services offered and give permission to Brenda Kiss to perform such services as outlined above, and state that you have disclosed any information (health or otherwise) that may alter the effectiveness of services offered. You understand that if at any time you feel discomfort or have a problem with the session, it is your responsibility to voice your concerns.
Submit
HOME
Events
Free Meditations
FREE E-BOOK
SCHEDULE A CALL
Freedom Forever Community
Free FB Goup