Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Reiki Immersion Session: New Client Form Question Title * 1. What is your first and last name and contact info (email and cell) OK Question Title * 2. How did you hear about us? OK Question Title * 3. Have you experienced Reiki before? Yes, I have had a 1:1 session before Yes, but only briefly in a workshop, yoga class or other event No, this will be my first time OK Question Title * 4. What is the main reason for scheduling this session? Physical issue Anxiety or Depression Overall well-being I've never had Reiki before and I want to experience it Other (please specify) OK Question Title * 5. What day and time preferences do you have for the session (check all days and times you are available) Morning (7am -10am) Late Afternoon (3pm-5pm) Evening (5:30pm or later) Monday Monday Morning (7am -10am) Monday Late Afternoon (3pm-5pm) Monday Evening (5:30pm or later) Tuesday Tuesday Morning (7am -10am) Tuesday Late Afternoon (3pm-5pm) Tuesday Evening (5:30pm or later) Wednesday Wednesday Morning (7am -10am) Wednesday Late Afternoon (3pm-5pm) Wednesday Evening (5:30pm or later) Thursday Thursday Morning (7am -10am) Thursday Late Afternoon (3pm-5pm) Thursday Evening (5:30pm or later) Friday Friday Morning (7am -10am) Friday Late Afternoon (3pm-5pm) Friday Evening (5:30pm or later) Saturday Saturday Morning (7am -10am) Saturday Late Afternoon (3pm-5pm) Saturday Evening (5:30pm or later) Sunday Sunday Morning (7am -10am) Sunday Late Afternoon (3pm-5pm) Sunday Evening (5:30pm or later) OK Question Title * 6. What is your favorite essential oil to smell (to be used in the diffuser for your session). I prefer not to have essential oils being diffused during my session Lavendar Geranium Sweet Basil Bergamot Chamomile Peppermint Lemongrass Cucumber Frankincense Surprise me! OK Question Title * 7. What describes you best I'm usually hot I'm usually cold Neither of the above apply OK Question Title * 8. Which would you prefer to listen to during your session? I'll bring my own playlist I prefer no music Spa-like music with no words, just sounds Blissful music, but I prefer music with words I've been to your Restorative classes before and I like the music you play there A mixture of both sounds and songs with words Surprise me - I have no preference Other (please specify) OK Question Title * 9. Let us know how you feel about the following: Please use when possible No preference I'd prefer you don't use Heated blanket Heated blanket Please use when possible Heated blanket No preference Heated blanket I'd prefer you don't use Weighted blanket Weighted blanket Please use when possible Weighted blanket No preference Weighted blanket I'd prefer you don't use Reflexology Reflexology Please use when possible Reflexology No preference Reflexology I'd prefer you don't use Vibration mat Vibration mat Please use when possible Vibration mat No preference Vibration mat I'd prefer you don't use Guided meditation or visualization Guided meditation or visualization Please use when possible Guided meditation or visualization No preference Guided meditation or visualization I'd prefer you don't use Affirmations and/or mantras Affirmations and/or mantras Please use when possible Affirmations and/or mantras No preference Affirmations and/or mantras I'd prefer you don't use Crystal bowls or koshi chimes Crystal bowls or koshi chimes Please use when possible Crystal bowls or koshi chimes No preference Crystal bowls or koshi chimes I'd prefer you don't use OK Question Title * 10. If there is somewhere you prefer not to be touched (other than the obvious), or anything else that would be good for us to know - please tell us here. For example, if you are extremely ticklish on your feet etc. OK DONE