Thank you for electing to have a Reiki treatment!
Your healing has already begun just by making the decision.
Please answer this form as thoroughly as you are able.
It will assist greatly with the success of your treatment(s).
All information is kept in the strictest of confidentiality.
It will not be shared in any form unless you, specifically request it in writing.
Family Information
Occupational Information
Medical History :
(i.e., chronic illnesses, any major surgery). List any medications and/or vitamins/herbs:
Why do You seek Treatment:
Describe the condition or situation which you would like to change with the help of my service:
How Do You Feel About the Following:
In answering please focus on problem areas or difficulties, and be as specific as possible.
i.e., "My mother and I haven't spo-ken in 20 years" tells me more than "I don't get along
with my family. Ask yourself, as you consider the following areas, "If there were one
thing I could change, what would it be?")
a) Your present occupation: (i.e., bored, frustrated, difficulties with fellow employees or boss, love it...)
b) Your relationships with members of your family
(describe any problems with particular individuals--in-laws count!)
c) Your marital or partnership relationship
c) Your marital or partnership relationship (if in one, or lack if not)
d) Your emotional health:
(including degree of self-esteem, decisiveness, intuition, resentment, anxiety--
anything that seems to stand between you & happiness.)
e) Your physical health :
(degree of discomfort, chronic versus new issues, etc...)
f) How do you feel about your spiritual development?
If there is anything else you would like to tell me:
So that I don't recommend a healing modality or practice you already use,
please list, if any, the alternative healing modalities you've experienced:
List, if any, the spiritual tools you use:
(prayer, meditation, affirmations, yoga, visualization, crystals, Reiki),
and the frequency with which you use them
(like "I give myself a Reiki treatment twice a week" or "I meditate daily"):
List any transformational workshops or seminars that you have participated in:
List any body work that you have received on a regular basis:
(Reflexology, Polarity, Feldenkrais, Alexander Technique,etc.)
List any religious/celebrity/political figures whose work has influenced you:
Again, anything said or done during treatment is strictly confidential,
what goes on here stays here.
- Your information will not be shared with anyone.
- Your e-mail address will not be provided to any third party - Government or private.
- We do not create individual profiles with the information you provide.
- We do not collect information for commercial marketing.
Please read and submit below:
I understand and agree that any information I receive from Leslie Fisher
is not to be construed as directions, recommendations, or prescriptions of
any kind. Said information is not to be interpreted as a substitution for,
or an addition to, medical advice, opinions, or treatment from a qualified physician.
I agree to indemnify and hold Leslie Fisher harmless from any and all
claims and from any and all loss, damage, liability or expense, including
cost of suit and attorney's fees, resulting from or arising out of my use
of said information for the above mentioned purposes.
Please give 24 hours notice for cancellation.
I understand there will be a $25 "no show" fee.
By submitting your Reiki Pre-Treatment Questionnaire, you agree
to these terms and conditions. If you do not agree, you should not
submit the Content of the Questionnaire to this Site.
