Modern Mystics | Intake Form

Date

First name

Last name

Email

Phone

Address

Birthday

Who do I have to thank for your interest in Modern Mystics Reiki?

Have you had a reiki session before ?

Yes

No

Do you require accessibility accommodations (wheelchair access or difficulty with stairs) Please explain.

What are you hoping to get from this Reiki session? Ex: Is there something in your emotions, life, or body you're hoping to shift or release from this gentle energy work?

Are there areas of your body you would prefer the touch be focused, areas to avoid or no touch reiki? (Ex: I could place hands just on the shoulders or head, or do the full body sequence, including arms and legs, or no touch)

Do you prefer any extra supports on the reiki table?

support pillow under the knees

inclined upper body support

Do you prefer more verbal communication during the session, or more silence?

More verbal communication

More silence

A mix of the two

Do you have any sensitivities to scents Ex: essential oils, fragrances, etc.

Please list any allergies

Are you under the care of a doctor

Yes

No

Doctor name and number

Do you have/had any of the following?

Please List any other health conditions or concerns

Are you currently or have you ever used any other holistic healing methods? Please list.

Do you have any additional concerns or questions?

Please read and agree to the Waiver and Consent Form

I have read the Waiver and Consent Form and agree to the terms.

Signature

Modern Mystics Intake Form