Energy Healing Session/Client Consent

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Session Date
Date
Month
Day
Year
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Name* This field is required.
First Name
Last Name
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Preferred Name (if any)
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Pronouns (optional)
5
Birth Date
Month
Day
Year
6
E-mail* This field is required.
example@example.com
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Phone Number (Text Reminder Optional)
8
Time Zone
9
Emergency Contact* This field is required.
First Name
Last Name
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Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
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Women only: Are you pregnant?
Yes
No
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If yes, due date:
Date
Month
Day
Year
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Check or describe anything relevant to your wellbeing:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Chronic fatigue or pain
Stress / Anxiety / Burnout
Depression or mood imbalance
Trauma / PTSD
Nervous system issues
Recent surgery or medical diagnosis
Pregnancy
Sensitivity to energy / emotions
High emotional reactivity
Difficulty sleeping or resting
Chronic fatigue or pain
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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Please list any special health issues or requirements you would like me to know about (include health restrictions, allergies or other health concerns):
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Have you ever had a Crystal or Reiki session before?
Yes
No
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Are you currently receiving medical or mental health support?* This field is required.
Yes
No
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If yes, provider’s name/specialty (optional):
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Are you taking any medications or supplements you'd like to disclose (optional)?* This field is required.
Yes
No
Other
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Have you had Reiki before?* This field is required.
Yes
No
Other
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If yes, how often?
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What are your intentions or desired outcomes for this session or series?
Huge
Large
Normal
Small
Ok
Ok
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Any specific area (physical or energetic) you'd like me to focus on?
Huge
Large
Normal
Small
Ok
Ok
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Do you prefer:
Lying down during session
Sitting upright
Eyes closed
Guided meditation intro
Silent session
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Energy Self-Assessment Check-in
I feel grounded in my body
I feel emotionally balanced
I feel connected spiritually
I sleep/rest well
I manage stress with ease
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I feel grounded in my body
I feel emotionally balanced
I feel connected spiritually
I sleep/rest well
I manage stress with ease
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HIPAA-Aligned Confidentiality. All information is kept strictly confidential and stored securely. No session is recorded without written consent. Any notes taken are stored in a HIPAA-compliant cloud service. Consent to Receive Virtual Reiki I understand this is a virtual energy healing session. I acknowledge Reiki is not a medical treatment and does not replace licensed care. I understand the practitioner is not diagnosing or prescribing. I consent to receive this session from a distance.* This field is required.
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Informed Consent

· I understand that Reiki is a simple, gentle, Energy Healing 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 understand that any information exchanged during any session is educational in nature and is to be used at my own discretion.

· I understand that any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my permission.

· I understand that only the practitioner will have access to information in my file to enhance my healing.

· I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless both the practitioner and the facility/location where the services are provided.

·   I agree to pay for Distance Reiki sessions, should I request them, at the time of booking unless arrangements have been made prior to appointment.

·   I agree to give 24-hour notice, when possible, if I am unable to keep a future appointment.

· I understand and agree to the terms and conditions set out by this Client Information and Informed Consent Form and certify that the above information is true and correct.
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Client Signature
Clear
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Date
Date
Month
Day
Year
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Fate Into Destiny Wellness Center

Located in Willoughby, OH

Serving Worldwide

+1 (440) 423-5858
margo@fateintodestiny.com
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Type a question
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