California Client Information Form, Acknowledgement, & Consent to Receive Treatment

California Client Information Form, Acknowledgement, & Consent to Receive Treatment

(In accordance with California Senate Bill SB-577)
What is Reiki & Karuna Reiki?
Reiki and Karuna Reiki are forms of complementary health care practices, which have been found to enhance the body's ability to heal itself.

What Reiki & Karuna Reiki is not
Your practitioner is not a licensed physician, and Reiki/Karuna Reiki does not require licensing by the state. They are meant to be a complement to “healing arts services licensed by the state”; i.e., they are a complement to traditional Western medicine provided by doctors, nurses, and other licensed medical professionals.

Theory of Treatment
Stress, trauma, and illness restrict the natural flow of ki (chi) or “life force energy” through the body. By restoring the flow of life force energy through the body, Reiki rejuvenates the body’s ability to relax and, therefore, supports the body’s ability to heal itself.

Although one session may be adequate, long-term imbalances in the body sometimes require multiple treatments in order to allow the body to reach the level of relaxation necessary to bring the system back into balance. Improvement often requires commitment on the client’s part (e.g., willingness to make lifestyle changes) in order to fully benefit from Reiki treatment(s).

Nature of the Services Provided
During a Reiki/Karuna Reiki session, the client is asked to lie down. He/She remains fully clothed during the treatment session. The majority of the session will involve the practitioner holding his/her hands about 2-3 inches above the client’s body. If guided to do so, the practitioner will ask permission to place his/her hands on your body but only in a manner acceptable to you and within the legal limits of his/her practice as a Reiki/Karuna Reiki Practitioner.

Once the session begins, the practitioner allows the life force energy to flow through his/her hands, which may be experienced by the client as heat, coolness, vibrating, tingling, a light pressure, a slight pulling sensation, or nothing at all. The Practitioner may also use other hands-off techniques, such as sweeping the body of unneeded energy or using vocal tones to break up energy blocks. The practitioner is simply a conduit or channel of the life force energy. It is believed that the energy is guided by God/Source/Spirit for the physical, mental, emotional, and/or spiritual well-being of the client. Therefore, a specific outcome cannot be guaranteed by the Reiki/Karuna Reiki Practitioner.

Tracey Miles’s Qualifications
Tracey Miles is a certified Reiki Master/Teacher and Karuna Reiki Master/Teacher. She has been practicing and teaching Reiki since 2019 and Karuna Reiki since 2020.
ACKNOWLEDGE & CONSENT TO RECEIVE SERVICES - In order to use Tracey Miles’s services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will be provided with a copy for signature at your first visit. Tracey Miles will keep the original in her records for three (3) years.*

I have read and understand the above guidelines and disclosure about the treatments and techniques offered by Tracey Miles as well as her training and education.I have discussed with Tracey any concerns I have about the nature of the treatment that she will be providing.If I experience any discomfort during the session(s), I agree to immediately inform Tracey.I understand that Tracey is not a licensed physician and that the alternative services that she will be providing to me are not licensed by the State of California.I understand that it is my responsibility to maintain a relationship for myself and/or my child with a medical doctor.I understand that Reiki/Karuna Reiki is not a substitute for medical treatment or medications. I am aware that Tracey Miles does not diagnose illness or disease nor does she prescribe medications or recommend supplements. I understand that any suggestions that are provided to me should not be taken as a diagnosis or recommendation against the advice of a licensed physician or mental health professional.I have consented to use the services offered by Tracey Miles, and I agree to be personally responsible for her fees in connection with the services provided.If requested, I have been provided with a copy of California Senate Bill SB-577.
Client Acknowledgment

I have read and understand the above disclosure regarding the Reiki/Karuna Reik treatment(s) I will be receiving from Tracey Miles I have been provided a copy of the above document, in accordance with California State Law SB-577:
Name of Client *

First NameLast Name
Name of Person Signing (if different) and Relationship to Client
Name and relationship
Email to receive your copy
example@example.com
Date Signed*

MonthDayYear
Date
Signature*

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