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Sample Intake Form

Dear All,

A few of you have asked me for this and it just occurred to me that I can put it up here. Below is a sample of my intake form that I have my clients fill out when they get to my office. Or in this environment, e-mailing it to my clients and having them sign it.

Key things to note about it.

  1. Getting their emergency contact information in case something happens to them is important. I have never had a situation where I had to call a loved one to come pick up their significant other. However, if a client gets dizzy after a session and you do not feel like they should be driving/travelling by themselves, that's when you call the emergency number to make sure they are safe. This is also in case of clients who are terminally ill and cannot travel by themselves.

  2. Asking them how they heard about you shows you what marketing material is working and what isn't.

  3. Asking how many times they have done Reiki/Energy work tells you how to approach their session. If they are a complete novice, you will have to do some explaining on what energy work is and what to expect from a session. If they have done it many times before, you might want to consider asking them why they are changing to another healer.

  4. Asking whether they are sensitive to touch or smell also tells you how they prefer their sessions to be approach. If they cannot bare touch, you will have to do your session completely hands free. If they cannot stand smells, you shouldn't use any essential oils or perfumes. This is particularly important as some clients are highly allergic to certain smells that can cause anaphylactic shock. I have had one client allergic to Lavender who recounted an incident to me that she walked past a store using an essential oil diffuser and that was enough to make her throat swell up.

  5. The last part of the form is the most important as that is considered a waiver form. It is designed to protect you in case a client comes back and claim that your services did not do what it was said to do. Have a read through it to make sure you understand what it says too. Remember, we do not tamper with prescriptions, we do not give prescriptions, and we do not go against Western Medicine. This legally would get you into a lot of trouble.

Reiki First Patient Treatment Form
Download PDF • 877KB

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