Reiki Forms Reiki Consent Form Name * First Name Last Name Email * Please Mark The Box To Consent I confirm I am at least 18 years of age, or have parental / guardian permission. I have elected, by my own decision, to have a Reiki therapy session. I confirm that I am not under the influence of recreational drugs or alcohol. The procedure, including the process and objective, has been explained to me before undergoing Reiki. I understand that Reiki is a simple, gentle, hands-on energy technique used for stress reduction and relaxation. I understand that a Reiki session is not a substitute for medical or psychological diagnosis and treatment. I also understand that it is not massage therapy. I understand that it is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that participation is voluntary and that at any time I may choose to end my participation. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level to relaxation needed by the body to heal itself I have been given the opportunity to ask questions regarding any benefits, risks, or possible complications of the procedure. I have followed all pre-treatment care instructions as they have been explained to me. I understand all aftercare procedures for Reiki as they've been explained, and I intend to adhere to the instructions given to me. I understand that it is important to provide feedback during my treatment, and will inform my Reiki Practitioner of any pain or discomfort during the session. With my signature below, I confirm that I have read fully and understand the information in this consent form and all details included. I have provided an accurate account of my medical history including any medications I take or intend to take, and any medical procedures I intend to undergo. By signing below, I agree to accept all and full responsibility for any risks, injuries, damages, or side effects that may occur as part of the procedure. I will not hold my Reiki Practitioner (recorded below) responsible for any conditions present, but not disclosed at the time of treatment, that may affect the treatment. * Message (optional) Thank you! Reiki Intake Form Name * First Name Last Name Birthday * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### How did you hear about Amy Conn Reiki? * Have you ever had a Reiki session before? * Yes No If yes, when was the date of your last visit What is your goal for this Reiki session? * Please list any specific area(s) of concern: Do you have any difficulty lying on your back for the entire session? * Yes No Do you have any sensitivity to perfumes or fragrances? * Yes No Are your feet sensitive to touch? * Yes No Are you comfortable with a light touch during a Reiki session? * Yes No Medical History: Are you pregnant * Yes No If yes, how far along and are there any concerns? : Do you suffer from chronic pain? * Yes No If yes, what makes it feel better or worse? Are you taking any medications? If so, please list. Have you had any orthopedic injuries? If yes, where?: Please check if any of the following conditions apply to you: Cancer Fibromyalgia Join replacement Diabetes Stroke Heart Attack Sprain/Strains Headaches/Migranes Arthritis Numbness Kidney Dysfunction High/Low Blood Pression Blood Clots Depression Anxiety With my signature below, I confirm that I have accurately completed the above information to the best of my knowledge. I agree to notify my Reiki Practitioner of any other relevant information that may affect my treatment, including any changes to the information above. I agree to communicate with my Reiki Practitioner about any pain or discomfort experienced during or after the procedure. I release my Reiki Practitioner of any and all liability of injury or damages that may arise because I have not represented my medical history accurately. * Please type and date Thank you! Thank You! Sign up with your email address to receive news and updates. Email Address Sign Up Thank you!
