Reiki Intake Form

Please complete this form before your first Reiki session.

It helps me understand what you’re currently experiencing, what you may need, and how I can best support you. All information you share is kept strictly confidential between client and practitioner, and is used only for general assessment.

I recognize that sharing personal details can feel vulnerable. I will receive your words with respect, care, and without judgment.

Name*

Email*

Phone*

Emergency Contact*

Have you received Reiki before?*

Yes

What brings you to Reiki at this time? (e.g., stress, grounding, emotional release, clarity, healing, curiosity)*

How does stress or imbalance typically show up in your body.mind?

Tell me about any self care rituals you already have.

What would you love to receive or release? (grounding, rest, clarity, emotional support, nervous system reset, healing)*

Reiki may involve light, gentle touch or may be done completely hands-off. Please check all that apply:*

Light, gentle touch is okay

Hands-off only

Please ask before any touch

Avoid specific areas

To help create a comfortable space, are there any scents or sounds (music, palo santo, sage) you prefer or wish to avoid?

Anything else you’d like me to know?

Consent & Acknowledgement

I acknowledge:

• Reiki is a gentle, non-invasive energy healing modality that supports relaxation, stress reduction, and overall well-being.

• Reiki is not a substitute for medical or psychological treatment.

• No specific outcomes or results are guaranteed.

• I am responsible for communicating any discomfort, emotional overwhelm, or physical needs during the session.

• I may choose hands-on touch, hands-off Reiki, or decline touch at any time.

• Information I share will remain private and confidential.

• I am participating voluntarily and may stop the session at any time.

I have read and consent to receive Reiki from Amy at Light, Love & Reiki.

Signature*

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Date*

Month

Day

Year

How did you hear about Amy / Light, Love & Reiki?

Friend / Family referral

Social media (Instagram, Facebook, etc.)

Namaspa Yoga & Massage

Website / Google search

Event / Workshop

Other

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