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Reiki Intake Form

Welcome visitors to your site with a short, engaging introduction. 

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Which session calls to you?
Reiki (60 min) — a full session for relaxation, energetic balance, and nervous system support
Reiki Mini Session (30 min) — a quick reset
Not sure yet — help me choose
Touch preference
Gentle hands-on touch
Hands-hovering only (no direct contact)
No preference — practitioner's discretion
Where are you in your journey with energy work?
Brand new & curious
I've tried it a few times
I have a regular practice
What's your main focus today?
Do any of these apply to you? Pacemaker or other electrical implant, currently pregnant, recent surgery or an open wound, contagious illness or fever, or a current mental health crisis. *
Yes
No

Consent & Acknowledgement


By checking the box and typing my name below, I acknowledge and agree to the following:

– Reiki is a gentle energy practice offered through consent-based touch or hands-hovering techniques. Sensations such as warmth, tingling, deep relaxation, or subtle emotional release are common and generally temporary.

– My participation is entirely voluntary. I can request a different touch preference, ask my practitioner to pause, or stop the session at any time for any reason.

– Reiki is not a substitute for medical or mental health treatment. If I noted any of the comfort/safety items above, I understand my practitioner may adjust the session accordingly.

– I have honestly disclosed relevant information above so my practitioner can support me safely.

– I release Confluence Breath and Bodywork, its practitioners, and staff from liability for claims, injuries, or losses arising from my voluntary participation, except in cases of gross negligence or willful misconduct. – have read, understood, and agree to the terms above

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