Energy Healing Intake Form

Personal Information

Full Name

Pronouns

Date of Birth

Email

Phone

Address

Emergency Contact

How did you hear about us?

Astrological Profile

Sun sign — select yours

Moon Sign (if known)

Rising Sign (if known)

Human Design Type (if known)

Physical Health

Past injuries or surgeries

Recent or current health conditions

Current medications or supplements

Are you experiencing physical pain?

If yes — location, quality, duration

Pain intensity

None

Severe

Areas of physical tension or holding

Mental & Emotional Landscape

Current mental or emotional challenges

Tell me more about your emotional world right now

Stress level this past month

Very low

Overwhelming

Sleep quality & patterns

Any history of trauma you'd like me to be aware of?

Spiritual & Energetic Life

Current spiritual challenges or areas of focus

Describe your spiritual path or practice

Do you feel connected to a sense of purpose or meaning right now?

Have you had any significant spiritual experiences, awakenings, or dark nights of the soul?

Do you notice sensitivity to energy — your own or others'?

Intentions & Goals

What brings you to energy healing at this time?

What would you most like to experience or shift through our work together?

Have you received Reiki or energy healing before?

Is there anything else you'd like me to know before our session?

Consent & Acknowledgement

Signature (type full name)

Date