Consultation Form

Please select what treatments you are having?

MassageFacialReiki

Personal details

First Name

Surname

Date of Birth

Address Line 1

Address Line 2

City

County

Postcode

Email

Contact Number

Medical details

Are you currently taking any medication?

Please provide details of medication?

Are you currently pregnant

Do you have any allergies or sensitivites?

Please provide details of any allegies

Please provide details of your skin type:

Oily

Combination

Dry

Sensitive

About your Reiki session

Have you ever had Reiki before?

What are the areas you would like the session to focus on?

What are your intentions for this session?

What is your current Stress Level?

Stress Level

Calm Slightly stressed Very stressed

What is your current Energy Level?

Energy Level

Low/Fatigued OK Energised

Are there any areas of the body you would prefer I avoid touching during the treatment? (For example, some people are sensitive about their feet, head, or hands). Please note that professional boundaries are always respected

I confirm that the details provide are correct

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Signature

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