New Client Intake Form-Reiki

I appreciate you taking the time to complete this intake form. I look forward to providing Reiki to you at your scheduled session.

Best wishes,
Marsha

Marsha R. Drozdoff, MSW, LCSW, Usui & Karuna RMT

New Intake Form-Reiki

Name
First Last
Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Emergency Contact and Phone Number
DOB
Date of Session
Level of Education completed:
Are you presently under a doctor's care for any medical conditions?
If yes, please explain
Medications and herbs you are presently taking:
Have you ever been hospitalized for a psychiatric disorder?
If yes, please explain
Have you experienced reiki before?
What are your goals related to receiving this reiki session?
If you are presently experiencing pain, please describe the pain, including what it feels like, where it is located, what have you been told about your condition, what makes it better, what makes it worse, how has it impacted your life.
On a scale from 0-10 with 10 being the worst, how would you presently rate any physical discomfort?
Is there anything else that you would like to share with me about your background or prior experiences?
Have you experienced any trauma that might affect your ability to relax? If so, please describe:
How were you referred to Desert Reiki Connection?
If other, please explain.
Name of person who referred you to Desert Reiki Connection (if applicable)
Date
FEES: To pay via PayPal (or by credit card), fill out the following fields. When you press submit, you will be directed to PayPal. If you do not want to pay online, skip the fields below and press submit.
1/2 hour session
Price: $60.00 Quantity:
1 hour session
Price: $85.00 Quantity:
1.5 hour session
Price: $125.00 Quantity:
Additional fee for session in your home
Price: $50.00 Quantity:
Mark this field if you would like Marsha to come to your home. This is an additional fee on top of the session fee.
Additional fee for Marsha to bring table
Price: $25.00 Quantity:
Mark this field if you would like Marsha to bring her table. This is an additional fee on top of the session fee.
Total
$0.00

New Client Intake Form-Reiki

New Intake Form-Reiki

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