Temple White Lotus, LLC.

Client Name

Phone Number

Mailing Address

City, State, Zip

Email

Would you like to be added to our mailing list?

Occupation

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Have you had or experienced Reiki before?

If yes, for what purpose?

What is your intent for this Reiki Session?

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?

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 by Rev. William L. Chamberlin, RMT

Client Electronic Signature

Date

Temple White Lotus Community of Las Vegas