Welcome to Reiki & Spiritual Wellness with Contessa Louise.
Please complete this Intake Form.
Reiki is not a substitute for traditional medical treatment, if you have a serious health condition you should see a Doctor or other appropriate professional. Reiki is a complementary healing part of a complete health care program.
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What is your full name? *

As it appears on your birth certificate or medical records.
 
How do you self identify? *




 
Which year were you born in? *

 
On which day of {{answer_oYVUd2wtFc9u}} {{answer_Pn2e4OY4Q6rj}} were you born? *

 
What is your address? *

 
What is your phone number? *

 
Will I need a pass, gate code or additional instructions for parking my vehicle?

 
Thank you for sharing your personal details with me

We now just need to ask you a few more questions about any symptoms or concerns you may have.
 
Do you have any allergies?

Be careful to list all allergies, including any allergies to medication.
 
Are you currently pregnant or is there a chance you could be? *

     
 
Are you currently taking any Medications/Remedies/Supplements? List them and the reasons why. *

 
List any significant Accidents, Injuries or Surgeries. *

 
Have you had any of the following conditions? (past or present)


 
Are you experiencing any of the following symptoms?

Almost done. I promise.

 
Would like improvement in any of the following areas? *

Last one

 
Which of the 3 choices from above is the most important to you? *

 
Is there anything else you would like for me to know?

Thank you.
Your Intake Form has been submitted successfully.
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