My full name
Email
address
Phone numbers
Street address, city, zip code
I am familiar with Reiki and/or
have previously had a Reiki session
Yes
No
I request Reiki for (check all that apply)
Myself
My
animals
Session length for myself
60 min
30
min
What do you hope to gain from this Reiki session (please be
detailed)
My existing medical conditions are (please be detailed)
My current pain level is
LowMedium
High
My current stress level is
LowMedium
High
(If applicable) The animals I am requesting Reiki for this session are:
Pet 1:
Name
Type (cat, dog, bird)
Session length
5
min
10m
15m
20m
25m
Reason (how this animal can benefit
from Reiki)
Pet 2:
Name
Type (cat, dog, bird)
Session length
5
min
10m
15m
20m
25m
Reason (how this animal can benefit
from Reiki)
Pet 3:
Name
Type (cat, dog, bird)
Session length
5
min
10m
15m
20m
25m
Reason (how this animal can benefit
from Reiki)
More Pets
(list all the above for each additional pet for whom you want Reiki)
I prefer to have my session at (check all that apply)
Your
home
My
home
For my home, I'm available next week on (check all that apply)
Tues-7p
Wed-7p
Sat-3p
Sat
4:30p
For yours, I'm available next week on (check all that apply)
Fri-7pSat-9a
Sat-10:30a
Sun-9a
Sun-10:30a
Please tell me anything else that would be helpful to me to know
I understand that the amount due at the end of our session is $,
which is $
for my treatment and/or
a
combined total of $
for my animals plus $
for the travel surcharge (if applicable).
Iraq/Afghanistan
veterans: free.
|
Session Length |
60
min |
30 min |
25 min |
20 min |
15 min |
10
min |
5
min |
Travel
Surcharge |
Add
$10 if you
live 0-10 min
from me, 1 way |
Add
$15
if you
live 11-20 min
from me, 1 way |
Add
$20 if you
live 21-30 min
from me, 1 way |
|
Rate |
$48 |
$24 |
$20 |
$16 |
$12 |
$8 |
$4 |
Your typed name serves as your signature that you understand the
statement below.
I understand that I am responsible for and must take an active role
my own healing and that long-term
imbalances
may require multiple Reiki sessions. I give permission to "lay
hands" and understand that body
privacy is respected.
I understand that you, as the Reiki facilitator, only aid in the process
by serving as a channel
for the Reiki energy and bear no
personal
responsibility for my outcome. I understand that the Reiki facilitator
does
not diagnose conditions, prescribe substances,
perform medical
treatment, nor interfere with the treatment of a licensed
medical
professional and does recommend seeing a
licensed medical professional
for physical or psychological ailments.
The facilitator
may make suggestions but I
must determine
if those suggestions are right
for me.
Typed
Signature
Date
Look for an email from me with 24 hours of my receipt of this
reservation form to advise you of my availability.
your
completed form to me.
to clear your form WITHOUT
submitting it. |