Please complete this form before your first session. Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Phone * (###) ### #### Landline (###) ### #### Emergency Contact * First and Last Name Mobile Phone * Emergency Contact (###) ### #### How did you hear about us? * Social Media Website Word of Mouth Event Print Ad/Flyer Other Have you ever had a Reiki Session before? * Yes No Do you have a particular intention or area of focus for this session? * Are you sensitive to perfumes or fragrances? * Yes No Are sensitive to touch? * Yes No Disclaimer * I understand that Reiki is a simple, gentle, hands-on energy technique 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, prescribe substances, nor 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 also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. I agree. Thank you! We look forward to sharing this space with you. Prism Lights LLC
