Holistic Alchemy | Reiki Therapy Johnson City TN

Intake Form

Your Name
Your Email Address
Your Phone Number
Current physical or mental health concerns?
Medications or supplements?
History of anxiety, trauma, or emotional sensitivity?
Cardiovascular, respiratory, neurological conditions?
Sleep quality
Stress level (1–10)
Movement/exercise habits
Nutrition patterns
Why are you seeking this session?
Desired outcomes?
Previous experience with breathwork, Reiki, meditation, or coaching?
Type YES: Acknowledge services are educational/supportive only.

Breathwork / Energy Work Contraindications Checklist

Clients should consult a provider before breathwork if they have:
    •    Uncontrolled hypertension
    •    Cardiovascular disease
    •    Seizure disorders
    •    Pregnancy (especially high-risk)
    •    Severe psychiatric instability
    •    Active substance intoxication
    •    Recent surgery or respiratory illness