Client Information (please print)

Name: _______________________________________________
Address: ___________________________________City: ___________________State: ___
Zip: _____
Cell Phone*: (______)______________________
Email Address*: _____________________________________
Date of Birth: ______________________________
Occupation: _____________________________________
Sex (please check): Male __ Female __ Pregnant: Yes __, Weeks: ___ No __ Possibly __
Physician or Health Care Provider: _______________________________
Primary Care Physician and their specialties: ___________________________________________
_______________________________________________________________________________
How did you hear about Shivaya Healing Arts ?
_____________________________________________________________________
Referred by: ___________________________________________________________________
Reason/Intention for session:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Have you experienced reiki or sound healing before? When? What was the experience like?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Do you feel your visit today will address your
Physical body ___ Emotions ___ Mental well-being ___ Spirit/soul ___
(Please check all that apply.)
Symptoms/Treatment Information (mandatory)
Do you have any diagnosed medical conditions? No __ Yes __, please explain: _________________
____________________________________________________________________
Are you currently taking any medications? No __ Yes __, please list: ____________________
____________________________________________________________________

Are you currently experiencing any physical pain or discomfort? No __ Yes __, please explain:
____________________________________________________________________________
____________________________________________________________________________
Are there any health related conditions, concerns or questions that you wish to disclose or ask prior to
your service? _________________________________________________________________
Injury Specific Information (if applicable)
Are you injuries related to an accident? No __ Yes __; Date of Accident: _______________
Was the accident automobile related? No __ Yes __; State in which accident occurred: _____
Are your symptoms employment related? No __ Yes __
Is there a Workers Compensation Claim? No __ Yes __, BWC Claim # _________________
Employer at the time of injury: ____________________________________________
Employer Address: __________________________________________________
Emergency Contact Information
Emergency Contact: ____________________ Phone Number: _________________________
Relationship: _________________Contact Address: ___________________________________
What are your main concerns for your overall well-being? Please list in order of signi ficance.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
If you are experiencing physical pain, please rate your level of pain, (0 being no pain and 10 being the
worst pain) ___
How do these conditions affect or impair your daily activities? _______________________________
What parts of your body does this pain apply to? Describe the sensation that you feel as best as you can
______________________________________________________________________________
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What is the stress level in your life? None _____ Minimal ______ Moderate _____ Severe _____
Do you have a restful sleep every night? ____________ How many hours of sleep each night? _____
Comments about your sleep: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Do you exercise regularly? ____ Describe your exercise regimen: __________________________
______________________________________________________________________________
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Close your eyes and take a moment to notice how you feel. Write and/or check all that apply to
describe how you are feeling.
Joyful __
Afraid __

Stressed __
Restless __
Sad __
Judged __
Irritable __
Happy __
Depressed __
Angry __
Anxious __
Grieving __
Worried __
Peaceful __
Overwhelmed __
Uneasy __
Impatient __
Shy __
Other __ Explain: _____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Do you feel you are on a spiritual / soul journey? ____________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Release Authorization for Treatment
I authorize wellness treatment provided by Shivaya Healing Arts. I have answered the health related
questions on this form honestly and completely. Though licensed in his or her specific service being
provided at Shivaya Healing Arts, I understand that my Shivaya Healing Arts therapist is not a medical
physician or doctor and cannot diagnose or prescribe any medications, treatments or services. I
understand that Shivaya Healing Arts and my therapist are not liable for any unforeseen medical issues
that I may experience or complications that may arise that could be related to an undiagnosed, preexisting medical condition prior to or after my treatment. I will disclose any concerns; health related or
otherwise as well as discuss any pre-existing conditions to my therapist prior to receiving a treatment. I
understand that I am responsible for my service charges at the time of service.
Client Signature: ___________________ Date: ____________ (Parent/Guardian if patient is a
minor)
Cancellation Policy
If you need to cancel or reschedule you appointment, please give us at least 24 hours notice prior to
your service. This is a courtesy to our therapist and will enable us to accommodate other clients. Thank
you for your cooperation. We appreciate your business. ___ (Client Initial)
**Thank you so much for taking the time to complete this information. It is an honor to share my gifts
with you to support you in your healing journey**