Hello! Please take a moment to fill out the form below before our first session together, so that we have ample time for healing work during the session. If you have any questions, please call me at 732-859-2544. Thank you!

Name

First Name

Last Name

Email Address

Home Address

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Address 2

City

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Zip/Postal Code

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Emergency Contact

First Name

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What are your goals or intentions?

Where or how do you want to see your healthy, your life, your career, the world? All desires and dreams are welcome.

Sensitivities or Allergies

Are you sensitive to fragrances, specific essential oils, or smoke (as in smudging herbs)? Please list any sensitivities or allergies below.

Consent: I understand that Reiki is a simple, gentle, hands-on (or hands-off, if requested) 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 understand that If I am unable to make my appointment I must provide advance notification within 24 hours in which case no charge will be applied.

Type your name below to agree.