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Confidential  Client  Information

Raven Spirit Studio, LLC

 Once your appointment has been scheduled, please print this form, complete, scan and email to

NAME (please print)

FIRST:  __________________________________________________________________

LAST:  __________________________________________________________________

PHONE NUMBER:   ___________________________________

MAILING ADDRESS:  __________________________________

                                      ________________________________________  ZIP:  __________________

EMAIL ADDRESS:  __________________________________________________________________

How did you hear about us?  __________________________________________________________

What are your reasons for scheduling a Reiki appointment?


Have you ever had a Reiki session before?  Yes _____         No _____

                     If yes, when was your last session?  ___________________

                     If yes, any experiences you’d like to share?  Any expectations not met?
                         Feel free to use the back of this form if additional space is needed.


Are you able to comfortably lie on your back or would you prefer a chair session?  Yes____    No ____

Are there any other accommodations you might need?  Yes ____   No ____


By providing my signature below, I confirm that the information recorded above is complete, accurate, and honest to the best of my knowledge. I understand that Reiki is a gentle, hands-on healing practice that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, counseling, prescribe substances, or interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I understand that I’m encouraged to tell my physician about my experiences with my Reiki treatments. I further understand that I am an active participant in my care.

Please sign here:  ______________________________________________________________  Date: ________

Please print signature here:  ____________________________________________________________________


Legal Guardian : Are you signing as the legal guardian for the client:  Yes ____    No ____

Legal Guardian Signature: __________________________________________  Date: ______

Please print Legal Guardian’s signature here: _______________________________________

Client’s Name (print): ________________________________________________________

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