Intake Form

Waiver of Liability

I (the client), agree to release Christy Gillham (Usui Tibetan Reiki Practitioner), of any responsibility or injury occurring from my sessions(s). You affirm that Reiki is appropriate for you and does not conflict with existing medical or psychiatric treatment. Always seek and follow the advice of your physician or other professional medical practitioner before considering alternative treatment.

I understand 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 palace of medical care. It is recommended that I seek 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.

Client Privacy Information

Confidentiality of Information: Clients have a right to expect that information revealed in sessions is not to be disclosed without extraordinary justification. The conditions that justify the release of information and by law must be reported to the appropriate agencies, which are the following:

●  Knowledge of child abuse or neglect.
●  Knowledge of senior citizen abuse or neglect.
●  A client poses a serious risk of suicide and is an imminent danger to self.
●  A client poses a threat of imminent danger to another person.
●  A judge, by issuance of court order, may obtain information.
●  Report to law enforcement authorities knowledge of a felony that has been, or is being committed.

In other situations, signed authorization for release of information is required.

Privacy Notice: No information about any client will be shared with any third party without written consent of the client and/or parent/guardian if under the age of 18 years old (unless serious and imminent threat of harm to self or others).