Reiki Immersion Session: New Client Form

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* 1. What is your first and last name and contact info (email and cell)

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* 2. How did you hear about us?

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* 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

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* 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)

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* 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)

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* 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!

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* 7. What describes you best

I'm usually hot

I'm usually cold

Neither of the above apply

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* 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)

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* 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

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* 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.