Please fill out this form before your appointment. Name * First Name Last Name Email * Martial Status: Do you have children? * If yes, please list names & ages. Briefly describe your current emotional health: Which emotions seem to dominate your life? Briefly describe your physical health: What concerns and issues are you hoping to address with this treatment? Have you ever received Reiki or any other type of alternative healing? If yes, please describe: What practices do you utilize to deal with stress? What activities do you enjoy in your leisure time? Do you have any spiritual practices? If yes, please describe: Services rendered through Kellie Springer are not meant as a substitute for medical or psychological diagnosis. It is recommended you see a licensed physician or health care professional for any physical or psychological issues you may have. * I understand Thank you! Kellie will be in touch soon to confirm your appointment.