Client Form

Please fill out the form below before your session.

Your Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Home or Cell Phone

(###)

###

####

Your Email Address

Your Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name & Phone Number

Do you practice meditation?

Yes

No

Have you experienced a Reiki session?

Yes

No

Have you experienced a channeled session?

Yes

No

Do you have any concerns physically or emotionally that I should know about?

Yes

No

If yes to the above, please list your concerns here:

What do you hope to gain from your Reiki, meditation, or channeled session?

Please read the disclaimer below. Enter your name and date if you agree:

Disclaimer

I understand that Reiki, Meditation and Channeling are gentle energy techniques that are used for stress reduction and relaxation. I understand that Reiki Practitioners, Meditation Teachers, and Channelers do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, or interfere with the treatment of a licensed medical professional. I understand that Reiki, Meditation and Channeling do 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 and Meditation may complement any medical or psychological care I may be receiving. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed for healing. In no way shall Terry Ciarfaglio at Inspired By Reiki be held responsible for the outcome of my session.