Insights Hypnosis & Reiki
Allentownhypnosis.com
610.737.9560
Animal Reiki Intake Form
OWNER’S/CAREGIVER’SINFORMATION: Please Print
Name: _______________________________________________________ Date:_____________________
Address:___________________________________________________________________________________________________________________
Telephone (home/mobile/facility):Email:
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How did you hear about me? _____________________________________
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ANIMAL’S INFORMATION:
Name or Description: ___________________________________________
Species:______________________________________________________ Breed: _______________________________________________________
Sex: _________________________________________________________
Age:________________
Show/Performance/Working (type)? Sheltered/Fostered/Adopted?
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Veterinarian:__________________________________________________
Date of last vet visit:
Current Medications/Supplements (flea, tick, heartworm, herbal remedies, etc.):_________________________________________________________
Exercise type and frequency:______________________________________
Is your animal sensitive to touch? _____________
Presenting Issue/Concern:
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How long has this issue(s) been present? ____________________________
What other medical or non-medical treatments or therapies are being provided to the animal (include previous Reiki sessions)?
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Other information, comments or questions:
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