Reiki Healing Intake Form

Date

First name

Last name

Phone Number

Emergency Contact Name/Phone Number

Have you had a Reiki session before?

Yes

Do you have a particular area of concern? i.e - stress, anxiety, pain

Reiki Waiver of Liability & Consent

By E-signing this form, you agree to the following:

I understand my consent for Reiki
is informed and voluntary and I may withdraw my consent at any time except for actions already taken.
I understand that I or the Reiki practioner may terminate the session at any time.

I release the Reiki practitioner and Reflections Yoga and Wellness LLC from all liability for any harm that may unintentionally result from any Reiki treatment.

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment. I understand that Reiki does not take the place of medical or psychological care. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

Signature

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