Reiki Intake Form · Light and Balance

About you

First name *

Last name *

Date of birth *

Email *

Phone *

City & Province / Country *

How did you hear about Light & Balance?

I'd like to receive occasional news and updates from Light & Balance

Health & wellness history

Brief physical & mental health history *

Please share any significant conditions, diagnoses, or history that may be relevant to your session.

Current treatments

Are you currently receiving medical, psychological, or other therapeutic care? If yes, please describe.

Reiki experience

Have you received Reiki before? If so, when and what was your experience?

Exercise

Do you exercise? If so, what type and how often?

Sleep

How is your sleep? How many hours per night? Is it generally restful?

Stress levels

Rate each area from 0 (none) to 5 (severe), or N/A if not applicable.

Work stress

Family / home stress

Health stress

Financial stress

Session preferences

Touch preference *

Reiki involves light touch and is not massage. You can always change your mind during the session.

Light hands-on touch Hands hovering above — no touch No preference — I'll follow your guidance

Positioning *

Do you have any difficulty lying on your front, back, or sides? Please explain if so.

Area of focus today *

Is there a specific area, concern, or intention you'd like to bring to this session?

What would you like to get out of this session? *

Photo (optional — distance sessions)

For distance Reiki, you're welcome to upload a photo of yourself or the intended recipient (with their consent). This can help me focus and channel energy more precisely — though it is not required.

Terms & policies

Reiki Terms & Conditions

Reiki treatments are given fully clothed on a therapy table. Reiki is not massage.
Reiki is used for stress reduction and relaxation only, and is not a substitute for medical treatment.
Reiki can complement any medical or psychological care you are receiving. Please continue to see your licensed healthcare providers for any medical concerns.
I do not diagnose conditions, prescribe treatments or substances, or interfere with the care of medical professionals.
Long-term imbalances may require multiple sessions. Healing is a process, and results vary by individual.
All information shared is held in the strictest confidence, except as required by law or in situations of credible risk of harm.
Please arrive 10 minutes early for in-person sessions and turn off electronic devices.
If you arrive less than 15 minutes late, your session will be shortened. More than 15 minutes late, the appointment will be rescheduled and the full fee charged.

Do you understand and agree to the above? *

I agree I do not agree

Cancellation & Refund Policy

There are no refunds on Reiki services already provided.
Please give at least 24 hours notice to cancel or reschedule.
No-shows who have paid in full will not receive a refund.
No-shows who have not paid will be charged the full session fee.

Do you understand and agree to the above? *

I agree I do not agree

Liability Disclaimer

I hereby release Maria Petropoulos and Light and Balance Reiki and Yoga from all liability arising out of any reliance upon advice or information given during the consultation or session, now or in the future. I assume all risks and responsibilities for myself and release Maria Petropoulos and Light and Balance Reiki and Yoga from any injury or liability that may occur during a treatment session.

Do you understand and agree to the above? *

I agree I do not agree

By submitting this form you confirm all information is accurate to the best of your knowledge. Maria will be in touch to confirm your appointment details.

Thank you ✦

Your intake form has been received. Maria will be in touch shortly to confirm your session details. We look forward to working with you.