Nana Catherine's Apothecary

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Email *

Intake Form

Please complete this form before our first session. Answer as honestly as you are able.

Name *

Pronouns *

Age *

Address *

Phone number *

Email *

Emergency Contact *

Are you currently receiving treatment for any mental or physical health conditions? *

Yes

Both

Please list any medications you are taking (this includes vitamins or herbal supplements). *

Is this your first time receiving Reiki, or any other energy work? *

Yes

Do you have particular areas of concern, or issues that you'd like to explore during our session? *

Yes

If yes, please explain.

Would you prefer to have your session in the hammock or a traditional massage table? (both have a maxium weight capacity of 450 lbs.) *

Hammock

Table

Either one

Not sure

Please check which tools you are comfortable with me using during our session. If you're not sure, please feel free to leave any of the boxes unchecked.

Crystals

Soft Music

Essential Oils

Smudges (I do NOT use sage or palo santo)

Herbs

Is there anything else about you, that would be helpful for me to know?

Please confirm that you've received/read the philosophies of my practice (https://nanacatherinesapothecary.com/pages/practice-philosophy) *

Yes

Required

Please affirm the following statements (as the recipient): I understand that Reiki and energy work practitioners do not diagnose conditions, nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. *

Yes

Required

I understand that Reiki and all energy work offered by Desiree, are energetic healing modalities, grounded in the body's ability to heal itself. *

Yes

Required

I understand that treatments received from Desiree at Nana Catherine's Apothecary are not to be construed as a substitute for medical examination, diagnosis or treatment. Energy work (Reiki, or otherwise) complements these treatments and is not meant to replace them. It is recommended that I see a licensed health care professional for any physical or psychological ailment I may have. *

Yes

Required

By typing my name below, I agree to having read, completed and understood the foregoing, and request to receive Reiki or other energy work treatments *

Today's date: *

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