Raven Spirit Studio, LLC

 Once your appointment has been scheduled, please print this form, complete, scan and email to ravenspiritstudio@gmail.com

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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.

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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.

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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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