Awareness

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

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

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

drink, eat, don't eat, shop, beat yourself up, shopping, etc.

Are you looking for (check all that apply) *

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

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

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.

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.

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

Intake and Consent Form for Reiki

Contact Us

B K.I.S.S. Be Kind-hearted Be Inspired Be Strong Be SereneIntake and Consent Form for Reiki

Contact Us

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

Intake and Consent Form for Reiki