Adult Intake Form. Please fill out the form if you are 18 years of age or older. Thank you for taking the time to tell me about yourself. I look forward to meeting you. Name * First Name Last Name Date of Birth * MM DD YYYY Current Age * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Phone Number * (###) ### #### Email * How do you wish to communicate with me for appointment reminders and follow up * Email Cell Voice Cell Text Occupation * Marital Status * How did you find us? * What is the main goal you would like to achieve with your session(s)? * List at least 5 benefits to achieving your goal * Do you feel that you have family support in your decision to seek self-improvement through our services? * Are you under the care of a physician for this current condition? Please explain. Provide name of physician. * Do you take any medication(s) for this current condition?: * Yes No Describe your current health: * If Applicable, have you ever been hypnotized? If yes, what was your experience?: * If Applicable, have you ever had Reiki session before? If yes, when was the last session, how many sessions have you had?: * Describe any fear or phobias you may have?: * Where is a peaceful place for you? A place you envision yourself in total relaxation and bliss: * Would you describe yourself as a spiritual person?: * Yes No Maybe Do you believe in God, God Source, Universal Energy, Spirit, a Creator, a Higher Power? * Yes No Maybe If yes, in what form? (person, an energy, a thought form, etc): * Do you believe in Angels? * Yes No Maybe Do you believe in spirit guides?: * Yes No Maybe Are you a visual person? (can you see material objects in your mind when you think of them?): * Yes No Maybe Is there anything I should know about you that would help me to understand what your goal(s) is/are with our sessions?: * Are you sensitive to perfumes or fragrances?: * Yes No Are you sensitive to touch?: * Yes No Although I do not anticipate an emergency as our services are safe and a comfortable experience, it is always good to have an emergency contact. In case of an emergency please contact: * Thank you for taking the time to tell me about yourself. I look forward to meeting you.
