Client Intake Form

for Energy Healing

Complete this form online, no later than 48 hours before your first session.

Answer all the ‘Required‘ questions in every section (if they’re not relevant please type ‘none’ or ‘N/A’). Some questions are only for a client aged 16 or under.

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Thank you

for completing the Client Intake Form

Section 1: General Information

Today’s Date (DD/MM/YYYY)

Are you the client?

If you’re filling in the form for a client, please answer the next 2 questions.

What is your full name and relationship to the client?

Is the client helping you fill in this form now?

Section 2: Client Personal Information

Full Name

Preferred Name (if different from above)

Date of Birth

Age

Address, including postcode

Section 3: Contact Details

If you’ve parental responsibility for a client aged 16 or under, only include your contact details (never include the young person’s contact details).

Mobile Phone

Landline Phone

If you’ve parental responsibility for a client aged 16 or under, and you’ve already included your contact details above, please include the details of another adult with parental responsibility for the client aged 16 or under.

Next of Kin Name

Next of Kin Email

Next of Kin Mobile Phone

Section 4: Client Health, Development and Disabilities

If you have any disabilities, do you need any reasonable adjustments made for us to work together?

For Reiki and Guided Relaxation only – Do you have any medical or physical health issues where relaxation and slowing down your heart rate would be difficult or dangerous for you?

For in person Reiki only – Do you have any medical, physical or developmental issues where you would find it hard to climb up or down from the Reiki bed, and when on the bed remain lying down or staying still?

Section 5: Help

What do you hope this energy healing will help you with?

If you’re filling this in for a client aged 16 or under, please answer all of the following questions:

The answer given in the previous question is…

Does the client think they need this help now? And why?

By typing your Full Name in the box below, Holistic Health York accepts this as your (the client or the person named who has parental responsibility for a client aged 16 or under) electronic signature.