First Name *
Last Name *
Email *
Daytime   Phone
Evening   Phone
Year of Birth
Address
State/ Province
City
Country
Zip/Postal Code

* Required Fields

1. For whom is this treatment? Include all names, and your relationship to the Reiki recipient(s). Has he/she/they given you consent to receiving this treatment?

2.  Describe the condition, situation or event for which you are requesting Reiki.

3.  Even if the treatment is meant for say grievance over a pet, or to boost the memory of someone doing an exam, please give a brief medical history of the Reiki recipient, and include the current medication the recipient takes. Provide specific details. For example, in case of heart issues, you must indicate if the recipient has a pace maker.If you have cancer, where is it located and has it spread, etc.

4.  What are the usual symptoms of the condition/situation for which you want Reiki?

5.  Do you see the recipient as an optimist?  Describe...

6.  Describe your/the recipient's lifestyle in terms of  smoking, drinking, eating, and exercise habits.

7.  How familiar are you/the recipient with energy healing?  Explain...

8.  Do you/the recipient have any scheduled clinical, or surgical procedures coming up? Please specify date and time.

9.  Are you/the recipient changing any of your doctor's recommendations to consider this treatment?

10.  Do you understand that I cannot guarantee any benefits you/the recipient might receive from treatment? Reiki goes where it's most needed and it's your soul who decides how to use the Reiki energy for your highest good.

11.  What emotional challenges are you currently working on (eg. as a result of your physical illness)?

12.  Please indicate any other problems/issues that bother you that you haven't told me yet.

13.  While believing is not a prerequisite for successful treatment, I would like know to which degree you believe in this Reiki treatment. Rate yourself from 1 (extremely skeptical) to 10 (completely identify with energy healing concept)

1    2    3    4    5    6    7    8    9    10

14.  If you are applying for distance reiki: do you have a photograph of your face/the recipient that you can email to me? (if so, please email it, and put the recipient's full name and location in the subject line of the email). There's no need to email me a picture for in-person treatment.

       yes, will email photo      no  

15.  Timing. Any particular day? What time of the day do you prefer to receive treatment? My preference for Distance Reiki is early mornings or the second part of evenings. In-person treatment times are usually mid-morning. 'Reiki at Home' , 'Reiki Bliss' treatment times are usually evenings, or weekends.

16. "I understand that Reiki is a stress reduction and relaxation technique. I acknowledge that sessions administered are only for the purpose of helping me relax and to relieve stress. Reiki Masters do not diagnose conditions, nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment or condition I may have.

I also understand the body has the ability to heal itself, and to do so complete relaxation is often beneficial. Long-term imbalances in the body require multiple sessions to allow the body to reach the level of relaxation necessary to bring the system back into balance. I understand and believe that self-improvement requires commitment on my part, and that I must be willing to change in a positive way if I am to receive the full benefit of Reiki.

I acknowledge my commitment to my self-improvement process. I recognize that a Reiki session program must be followed to be truly effective, just as prescribed medication is only effective if taken as directed."

* Please read the above disclaimer note and indicate your understanding and agreement to this treatment relationship BY TYPING YOUR NAME AND EMAIL ADDRESS in the box below. In doing so, you are acting on behalf of the Reiki Recipient, which most likely is you.

* Required Field

My PRIVACY POLICY is common sense: I respect the privacy of your contact details and personal information, take reasonable care to protect it, and won't sell it.