Name * First Name Last Name Email Phone * (###) ### #### Emergency Contact Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Current Medications and Dosage Are You Currently Under the Care of a Physician? Please Add Physician's Name Reiki May Include the Laying On Of Hands * Answer Even If Virtual, For Future Reference Include Laying On Of Hands Exclude Laying On Of Hands The Chest and Pelvic Regions Contain the Important 4th and 7th Chakras, however they are Considered Sensitive Areas of the Body * Treatment of These Areas Would Use Distant Reiki, but Can Be Avoided Entirely if Needed Allow Treatment of These Areas Avoid These Areas During Treatment Is There an Area That You Would Like Avoided? Are You Sensitive To Perfumes, Fragrances, Light, Sounds, Other? Have You Ever Had A Reiki Session Before? When Was Your Last Session? How Did You Hear About Us? Did Someone Refer You? * I Understand That There Is No Need To Remove Clothing During Treatment Checkbox * 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, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. 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 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. Privacy Notice: No Information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18. I Understand and Agree To Treatment Signed * I Certify That I Am an Adult Aged 18yr or Older, Or Will Have A Parent/Guardian Available at Time of Treatment Date * MM DD YYYY Thank you!