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First name

Last name

Phone

Email

Have you been diagnosed with any mental health conditions? If yes, please specify:

Are you currently receiving any form of mental health treatment or therapy? If yes, please describe:

On a scale of 1-10, how would you rate your current mental well-being? (1 being poor, 10 being excellent)

What are the primary mental health challenges you're currently facing?

Have you ever received Reiki or any other alternative therapy before? If yes, please describe your experience:

Why are you interested in receiving Reiki therapy specifically?

What do you hope to achieve through Reiki therapy?

How did you hear about Ora Foundation?

Is there any additional information you'd like to share about your situation or why you're seeking support from Ora Foundation?