Welcome, New Reiki Client!

Please fill out this form prior to our appointment and remember to drink plenty of water the day of and possibly the day prior to your appointment.

Name(required)

Email(required)

Phone(required)

Full Address with Street, City, State & Zip(required)

Would you like to join my email list to receive monthly newsletters with tips as well as stay up to date on promotions and events?

Have you received Reiki before? If, yes, please provide your last session date (it can be approximate)

What do you hope to accomplish with Reiki? (select all that apply)

If Pain Reduction was selected, please explain what areas need help:

Is there any other area you would like help with that is not listed above?