Client Intake Form | Abundant Energy

First name

Last name

Email

Phone

Birthdate

Address

Contact Preference

Text

Email

Emergency Contact (Name, Phone, Relationship)

Hare you ever received Reiki or Energy Healing?

Yes

No

Are you currently under the care of a physician?

Yes

No

If yes, please explain.

Please list any allergies

Are you sensitive to fragrance or touch?

Yes

No

Please provide 24 hours advance notice of any changes or cancellations. Failure to do so may result in a billing for the full service fee.

I understand that Reiki and Energy Healers are not licensed by the state of California. They do not diagnose illness, disease, or mental disorder. Nor do they prescribe medical treatment or pharmaceuticals. It has been made clear that energy healing is not a substitute for medical examination or diagnosis and that it is recommended that I see a medical doctor for any physical or mental ailment. With this in mind I agree that Abundant Energy cannot be held liable for any issues that may arise

Signature

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Abundant Energy Intake Form

Please complete and submit this form prior to your visit