In-Take Form

We look forward to meeting you. If you are a first time visitor to our studio please complete this brief in-take form. All of the information you choose to disclose in this form is completely confidential. I am the sole owner who has access to your private information. We only have access to/collect information that you voluntarily give me via email or other direct contacts from you. We will not sell or rent this information to anyone and we take precautions to protect your information. When you submit sensitive information via the website, your information is protected both online and offline.

Visitation Type:

How would you describe your experience with Reiki Healing?

Please explain what you would like to accomplish with your upcoming Reiki Healing

Do you have any expectations regarding what you will experience during your Reiki Session?

Do you have any preexisting medical conditions that I need to be aware of?

If yes, what are they?

How did you hear about My Healing Elements?