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

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.