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Angela E. Gallo

Usui/Holy Fire® III, Karuna Reiki® Master | Intergrated Enery Therapy® Practitioner®
PSYCH-K® Preferred Facilitator | Certified Emotion Code®, Body Code™ and Belief Code® Practitioner

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Intake for Reiki

Please fill out the following form and submit before appointment.

First name

Last name

Phone Number

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Preferred Pronoun

How did you hear about me?

Have you ever had a Reiki session befoe?

Yes

Are you currently under the care of a physician?

Yes

Please check the boxes to show that you have read, understood and agreed to the statements below.

I understand that Reiki is a simple and gentle 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 health care professional for any physical or psychological ailment I may have. I also understand that complete relaxation is often beneficial and facilitates the body’s ability to heal itself.

I also understand that complete relaxation is often beneficial and facilitates the body’s ability to heal itself.

I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to enable the level of relaxation needed by the body to heal itself.

Initials

I declare that the info I’ve provided is accurate & complete.

Thanks for filling out the Intake form!

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