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Temple White Lotus Community of Las Vegas
Buddhist Temple and Reiki Center in Las Vegas, Nevada
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Client Intake Form
Client Name
Phone Number
Mailing Address
City, State, Zip
Email
Would you like to be added to our mailing list?
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Occupation
Emergency Contact Name
Emergency Contact Phone
How did you hear about us?
Have you had or experienced Reiki before?
Yes
No
If yes, for what purpose?
What is your intent for this Reiki Session?
Relaxation
Stress Reduction
Pain Reduction
Other -- Please Explain
Other -- Please Explain
What are your commons areas of pain, tension, or complaint?
List any areas you would lik.e me to focus upon
Would you prefer hands on or hands off?
Hands on
Hands Off
Do you have any other concerns or anything you wish me to know?
I hereby grant free and knowledable conscent to be treated with Reiki, Seraphim Blueprint or Biomat by Rev. William L. Chamberlin, RMT
Yes
No
Client Electronic Signature
Date
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Thank you for contacting us. We will get back to you as soon as possible
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