Cosmic Reiki intake Form Name * First Name Last Name What is your preferred method of communication? * Please provide your preferred contact information below. Phone Email Phone (###) ### #### Email Date of Birth * Parental consent is required for clients under 18 years of age. MM DD YYYY How did you hear about Cosmic Reiki? * Facebook Instagram Personal Referral Internet Search Other Is this your first Reiki session? * Yes No What are you hoping to get out of the Reiki session? * Choose all applicable choices. Stress Reduction Pain Reduction Emotional Support General Relaxation Other If Other, please describe below. Are you sensitive to fragrances and/or perfumes? * Yes No Do you have any allergies? * Yes No If Yes, please provide further details below. Do you prefer a hands-on or hands-off session? * Hands-On Hands-Off Is there anything else I should know to ensure you have a relaxing and beneficial experience? If no, please leave blank. Thank you for completing the Cosmic Reiki Intake Form!I appreciate the opportunity to provide every client with a personalized experience.I will review the information prior to our appointment. If you have any additional information to share, please send an email to cosmicreikillc@gmail.com. I look forward to our appointment!Andrea Drago
