Reiki Treatment Application Form
Please complete this form to request your treatment. It's designed to allow me to best help you, and takes just little time to complete.
Your First and Last Name
Address (street + number, city, postal code, country
For whom is this treatment? Briefly describe the situation/all people involved, and relationships
Date of Birth of the person who will receive the treatment.
Provide brief medical history. Particularly indicate significant data, i.e. pacemaker, epileptic, cancer, etc.
Provide Further Medical Info: medicine, planned surgery (type/date), lifestyle factors.
Describe symptoms of the condition or situation for which Reiki is wanted, incl. emotional/mental challenges currently faced e.g. as a result of physical conditions.
Do you understand that I cannot guarantee any benefits you/the recipient might receive from treatment? Reiki goes where it's most needed and it's your soul who decides how to use the Reiki energy for your highest good.
Yes, I understand.
No, it's not clear to me how Reiki Energy works.
Indicate your preferred dates & times for treatment. Tip: type your location + Italy both at http://www.worldtimebuddy.com and you can easily see reasonable time slots.
Do Not Fill This Out