Intuitive Energy Healing and Reiki Appointment Form

Please note that all written or sessional information will be confidentially maintained. Date: Name: I am interested in an: Intuitive Energy Session Reiki Session Date of Birth: Email: Home Telephone: Work Telephone: Address: City: Province: Postal Code: Lanaguage/s: English French Other Languages Emergency Contact Person Name: Phone: City: Medical Conditions: Thyroid Disease Hypoglycemia Anemia Allergies Anxiety Disorders Food Sensitivities Mitral Valve Prolapse Inner Ear Problem Depression Vitamin Deficiency   Heart Disease Cancer   Other/s: (please list) Purpose of session: Do you have an established support system? Who? Please share a future dream or goal that you have: My favourite colour is: I sometimes/ chronically have pains/cramps/aches in the following places: I feel the following emotions quite a lot or chronically: I cannot feel the following emotions or body parts often/well: My best time of the day is: My worst time of the day is: Please answer the following questions. Yes No I have experienced a Reiki session before I have had an energy balancing session before I know about chakras I have used holistic remedies for my growth and development I have a spiritual path that I am consciously following I have experienced trauma I have difficulty adjusting to new situations and or people I am generally uncomfortable with touch I am generally uncomfortable expressing myself I love myself I accept myself I am comfortable asserting myself I feel like I belong I feel connected to the world around me Is there anything else you wish to share? Please enter the code shown into the box below