Reiki, Chakra Balancing and Energy Healing Intake Thank you for taking the time to fill out the requested information. Confidential when completed. PERSONAL INFORMATION Date: __________________ Name: _______________________________________________________________ Date of Birth(dd/mm/yy): __________________ Why are you here today? ________________________________________________________________________________________ _____________________________________________________________________________________________________________ What do you hope to achieve from this treatment or therapy? __________________________________________________________ _____________________________________________________________________________________________________________ Have you had energy healing before, if so what type? _________________________________________________________________ _____________________________________________________________________________________________________________ Do you wish to share with me any emotional or physical traumas you have experienced: _____________________________________ _____________________________________________________________________________________________________________ Please list any specific health concerns. _____________________________________________________________________________ _____________________________________________________________________________________________________________ Are you currently under the care of another health care provider? If so who and for what? ____________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Current medications: ____________________________________________________________________________________________ _____________________________________________________________________________________________________________ Anything else I should know? _____________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________