Reiki Intake Form - Marram Plapp MA

Name*

First Last

Gender*

Age

Birthdate*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Best phone number to reach you*

May I leave voice messages?

Yes
No

Your Email*

Enter Email Confirm Email

Emergency Contact

Relationship

Emergency Contact Phone

000-000-0000

Sexual Orientation

Relationship Status

Ethnic Background

Religion

Education Level

Occupation

Current Issues

Please provide a brief description of why you are seeking Reiki at this time? (This can be on a physical, mental, emotional or spiritual level)

What are your goals for today’s Reiki session?

What intention(s) would you like to set for today’s Reiki session?

Do you have any questions before your Reiki session?

Do you have any additional comments, or is there anything else you feel that is important for me to know before your Reiki session?

Reiki Session Needs & Preferences

Do you have any difficulty lying on your front or back for the session?

No Answer
Yes
No

If yes, please take a moment to explain:

Would you prefer a chair that keeps your body upright?

No Answer
Yes
No

During your Reiki treatment are you open to focusing on the intention you set for your session, using crystals, tarot, working on positive visualizations or simple meditation techniques, etc?

No Answer
Yes
No

Are there any boundaries or limitations you would like to make on what you additionally incorporate into your session?

No Answer
Yes
No

If yes, please take a moment to explain:

At the end of your session, would you like to be:

No Answer
Energized
Grounded

Is there a place where you would like to receive extra Reiki energy?

No Answer
Yes
No

If yes, where would you like to receive extra Reiki energy, and with what intention?

After your Reiki session time is given to process your experience. During this time would you like to receive intuitive feedback?

No Answer
Yes
No

Are there any boundaries or limitations you would like to make on the intuitive feedback you receive after your session?

No Answer
Yes
No

If yes, please take a moment to explain:

Reiki Treatment History

Have you had a Reiki Treatment before?

No Answer
Yes
No

If yes, please list the date(s) of your last session(s):

Date	Practioner

You may add as many lines as needed by clicking on the "plus" sign to the right of each line.

What were you being seen for?

What was your experience like?

How was it helpful and/or unhelpful?

History of Current Counseling/Therapy

Are you currently being treated by a counselor, psychologist, psychiatrist, and/or other physician for the problems noted above?

No answer
Yes
No

Please list professionals you are currently seeing for treatment:

You may add as many lines as needed by clicking on the "plus" sign to the right of each line.

Date	Name	Address	Treatment Type

What is helpful and working for you in your current therapy experience?

What is unhelpful and not working for you in your current therapy experience?

History of Past Counseling/Therapy

Have you ever been treated by a counselor, psychologist, psychiatrist, and/or other physician in the past?

No answer
Yes
No

Please provide information regarding previous treatment you have received from a counselor, psychologist, psychiatrist, or other medical or mental health professional for this or other problems:

You may add as many lines as needed by clicking on the "plus" sign to the right of each line.

Date	Name	Address	Treatment Type	Why Treatment Ended

What helped and worked for you previously in therapy?

What was unhelpful and didn’t work for you previously in therapy?

History of Hospitalizations

Have you ever been hospitalized for treatment of an emotional or mental disorder?

No answer
Yes
No

Please list the following information for each hospitalization:

You may add as many lines as needed by clicking on the "plus" sign to the right of each line.

Date	Hospital/Facility Name	Address

History of Current & Past Medical Conditions

Please list current and past medical conditions and treatment:

You may add as many lines as needed by clicking on the "plus" sign to the right of each line.

Date	Condition	Treatment	Results	Physician Name	Physician Addresss

History of Current Prescriptions & Medications

Please list all current prescription and over the counter medication use:

You may add as many lines as needed by clicking on the "plus" sign to the right of each line.

Start Date	Medication	Dose	Frequency	Condition Treated

History of Past Prescriptions & Medications

Please list any previous prescription and over the counter medication use significant to your counseling/therapy:

You may add as many lines as needed by clicking on the "plus" sign to the right of each line.

Start Date	End Date	Medication	Dose	Frequency	Condition Treated

History of Current & Past Substance Use

Please list any current or previous use of street drugs, tobacco products, or alcohol:

You may add as many lines as needed by clicking on the "plus" sign to the right of each line.

Start Date	End Date	Type Used	Frequency	Amount Used	Comment

One Final Thing:

Is there anything else that you feel is important for me to know?

No Answer
Yes
No

If yes, please explain:

Please carefully read the statement below

By signing below I understand that I am responsible for all fees for services provided to me at the time of receiving services. I agree to the late cancellation/no show policy of paying the full fee for a session if I do not cancel or reschedule 24 hours in advance. I have read and understand my rights and the limits of confidentiality, privacy, and my rights as explained in the documents Consent to Treatment and Notice of Privacy Practices for Protected Health Information

By signing below I am consenting to receiving Reiki energy work. I understand that the treatment I am receiving is a stress reduction and relaxation technique, and I acknowledge that treatment administered is only for the purpose of helping me relax and relieve stress. Reiki is not a diagnostic tool and replacement for medical treatment. I understand that it is recommended that I see a health care professional for any physical ailment I may have. I understand that my Reiki therapist will not interfere with the treatment prescribed by a licensed medical professional. I also understand that this is not a massage therapy session, and that I will remain fully clothed (except for shoes and/or socks) during the entire session.

By signing below I understand and believe that the body has the innate ability to heal itself, and to do so complete relaxation is often beneficial. Long-term imbalances in the body sometimes require multiple treatments to allow the body to reach the level of relaxation necessary to bring the system back into balance.

By signing below I acknowledge and fully agree with the above information for this and all subsequent Reiki treatments.

Date

Full Name*

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