Distance Reiki Session Form

Thank you for deciding to have a Reiki treatment! The Reiki Energy is already flowing through you 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.

Part 1

Name:

Date of Birth:

Email:

Choose:
( ) Single
( ) Married/long-term partnership
( ) Divorced
( ) Other:

Partner’s Name (If applicable):

If you have children, please list their ages and sex:

Occupation(s):

Medical history (i.e., chronic illnesses, any major surgery). List any medications and/or vitamins/herbs:

Describe the condition or situation that you would like to change with the help of my service:

Part 2

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 spoken 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 (if in one, or lack if not):

d) Your emotional health (including degree of self-esteem, decisiveness, intuition, resentment, anxiety, or anything that seems to stand between you and happiness.):

e) Your physical health (degree of discomfort, chronic versus new issues, etc...):

f) Your spiritual development:
Part 3

If there is anything else you would like to tell me, please share it with me here:

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.

Selected method:
( ) Personal Distance Session
( ) Group Distance Reiki Session
( ) Full Week Group Distance Reiki Sessions
( ) Full Month Group Distance Reiki Sessions
( ) Full Week Personal Concentrated Distance Sessions


Please read and sign below:
I understand and agree that any information I receive from Master Midas 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 Master Midas 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.

Signature (full name): 
Date:
Paypal Transaction ID:

Please answer everything you can and send it to me.