-PRIVATE AND CONFIDENTIAL-

REIKI
CLIENT CONSULTATION FORM
 
Name: ......................................................................................................................
Address: ..................................................................................................................
              ....................................................................................................................
Phone No: ................................................. Mobile: ................................................
Date of Birth: ....................................
Referred by: .....................................
Reason for visit: .......................................................................................................
MEDICAL HISTORY................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
Length of time condition present: ..........................................................................
Current medication: ................................................................................................
...................................................................................................................................
General Practitioner:
Name: ................................................
Address: ..................................................................................................................
                ...................................................................................................................
Phone No: ..........................................
Signed:
            Reiki Practitioner: .........................................
            Client: .............................................................
            Date: ..............................................................