Client Intake Form

Client Intake Form

Complete Client Intake Form

Name*
First Last
Date of Birth*
DD dash MM dash YYYY
Occupation
Email*
Phone*
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Relationship Status*
Number of Children (if applicable)*
Services
Are you interested in Reiki, Reflexology, or Hypnotherapy as part of your treament?*
Certain physical and in-person services need a bit more information about your background.
- Yes
- No
- Not Sure
Reason for Seeking Treatment
Why are you seeking treatment just now?*
Any Other Relevant Information?
Are You Receiving Other Therapies Regularly, If So, What?
's GP
GP's Name*
GP Surgery*
GP Surgery Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Medical Information
Diagnosed Medical Conditions & Medication Details*
Please note that the following are contraindicated conditions: Severe cellulitis, fever or contagious illness, DVT or pulmonary embolism, or clients that are currently under influence or drugs or alcohol.
Caution Check
- Acute Undiagnosed Pain
- Allergies
- Diabetes
- Epilepsy
- Osteoporosis
- Cardiovascular Condition
- Varicose Veins/Phlebitis
- Imminent Medical Tests or Procedures
- Recent Surgery
If You Have Checked Any Of The Above, Please Give Details*
Medical Health History
Lifestyle
Describe Your Diet*
What Do You Drink In A Day?*
Bowl & Urinary Health
Smoking/Alcohol
What Do You Do For Exercise?
What Do You Do To Relax?
Describe Your Sleep Pattern
How Would You Rate Your Energy Levels?
How Would You Rate Your Stress Levels?
Other Information
- I am pregnant or trying to get pregnant. I have discussed the possibility of miscarriage and have been advised by the practitioner that there is no evidence to suggest that having reflexology can provoke a miscarriage, and am willing to go ahead with the treatment at my own risk
I declare the information in this form to be true and accept that it is my responsibility to keep my practitioner updated regarding any changes in my health or medication. I am happy to receive reflexology and any other therapies as listed above.
Consent*
I agree to the privacy policy.
- Check this box if you're signing on behalf of a child (Under 16)
- Check this box if you want to be kept up to date with EnerChi Vibes news, offers, and info via Whatsapp/Email
Signature*
Today's Date*
DD dash MM dash YYYY