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Fire Gateway Experiences

Psychic Mediumship Readings

Shamanic Services

Intuitive Spiritual Mentoring + Coaching

(New) Cacao Ceremony

Events + Classes

Events + Group Readings

Holy Fire® Reiki Experiences

Charity Fundraiser Event

Gift Cards

Folder: Services

Fire Gateway Experiences

Psychic Mediumship Readings

Shamanic Services

Intuitive Spiritual Mentoring + Coaching

(New) Cacao Ceremony

Folder: Events + Classes

Events + Group Readings

Holy Fire® Reiki Experiences

Charity Fundraiser Event

Gift Cards

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Email Address

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82 West Main Street,
2nd floor, Suite 5A
Northborough, MA 01532

(by appointment only)

mccarthyleo@gmail.com

About | Contact | Reiki | Fire Gateway Experiences | Shamanic Services | Psychic Mediumship Reading | EFT Tapping | Mentoring & Coaching | Reiki Classes | Events | Holy Fire® Reiki Experience | Resources

Reiki Intake Form 2

Name *

First Name

Last Name

Primary Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Emergency Contact *

Current Medications and Dosage *

Are you currently under the care of a physician? *

Yes

No

If Yes, what is your physician's name?

First Name

Last Name

How did you hear about us? *

Have you ever had a Reiki session before? *

Yes

No

If yes, when was your last session?

Number of Previous Sessions

Do you have a particular area of concern? *

Are you sensitive to perfumes or fragrances? *

Are you sensitive to touch? *

Yes

No

Consent *

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. I understand that no information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18. Please type your name below.

Date

MM

DD

YYYY

Thank you!

EFT Tapping Intake Form

Name *

First Name

Last Name

Have you had EFT tapping before? *

Yes

No

Do you have any mental health diagnoses? Please list and when diagnosed. *

Are you on any medications? If yes, please just list medication names. *

Are you involved with any talk therapy with a therapist? If yes, list their name and contact information. *

Do you have a primary care physician? If yes, please list their name and contact information. *

Are there any other medical conditions that have not been listed? If yes, please list medical conditions and if you are still being treated for them. *

Are there any other modalities that you are using for treatment for any conditions listed above? If yes, please list the modalities and how often it is used. *

What is your goal for today? What do you want to focus on for the session? *

On a scale from -10 to 10, where would you rate how you have been feeling on average. *

-10 meaning, 0 feeling nothing, and 10 feeling great

Why do you think you have been feeling this way? Please briefly describe below. *

Consent *

I understand that EFT Tapping is a simple, gentle energy technique that is used for stress reduction, anxiety relief and relaxation. I understand that EFT practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that EFT Tapping does not take the place of medical care. It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment I may have. I understand that EFT Tapping can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to come to a state of balance. I understand that no information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18. Please type your name below.

Date

MM

DD

YYYY

Thank you!

Vetted Healer

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