Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Session Type *

Distance Session

In-Person Session

Emergency Contact (for In-Person Sessions)

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Have you had Reiki before?

Yes

No

Do you have any specific areas you’d like me to focus on energetically?

Physical body

Emotions

Chakras

Spiritual connection

Other (please detail below)

Are you comfortable with light, non-invasive touch during in-person sessions?

Yes

No

Please check with me during session

Are you currently under the care of a healthcare professional? *

(GP, psychologist, specialist etc.)

Yes

No

Reiki is a gentle, non-invasive energy healing modality that supports the body’s natural ability to restore balance on physical, emotional, mental, and spiritual levels. During a session, Reiki energy is channeled through the practitioner to the recipient, either in person or from a distance, guided by intention and intuitive connection. Please note: Reiki is complementary, not a substitute for medical or psychological treatment. I do not diagnose conditions, prescribe medications, or interfere with the treatment plans of healthcare professionals. Reiki may bring about emotional releases or physical sensations, which are a natural part of energy shifting. These vary from person to person. For in-person sessions, light, respectful touch may be used (unless you prefer a no-touch session, just let me know). For distance sessions, your consent and openness are what allow the energy to flow. You are welcome to relax, meditate, or go about your day during the session. *

I understand that Reiki is a complementary practice and does not replace medical or psychological care. I agree to receive Reiki from Rebecca Lea and take full responsibility for my wellbeing.