In take Form (New clients only)

First Name

Last Name

Phone

Birthday

Address

Why would you like a Reiki session

Current medication/ dosage

Are there any physical, emotional or health related issues you would like to address in your session?

Is there any medical history I need to be aware of? i.e epilepsy etc

What would you like to get from your reiki session today?

Details of any other treatments being received

Do you mind touch? throughout a session there are some areas I place my hands, for example, feet, knees and shoulders.

Anything else you would like to add

How did you hear about me?

Usui & Seichem Reiki Practitioner