Sound / Reiki • Intake & Consent Form

Date

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

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Phone Number*

Please enter a valid phone number.

Emergency Contact

(NAME & PHONE NUMBER)

How did you heard about us?

What are your goals for receiving Reiki or Sound Therapy?

Pain reliefRelaxationAddressing a traumaOther

Are there any injuries, surgeries, or recent health conditions that you feel would be beneficial for us to know about?

We sometimes use sage, essential oils or incense during a session. Are you sensitive to these? If so, which ones would you prefer we NOT use?

Are you comfortable with a light touch during a Reiki session? (please indicate if you prefer hands-off treatment)

YESNOHANDS-OFF ONLYN/A

Are you comfortable with singing bowls being placed on your body during a sound healing session? (please indicate if you prefer hands-off treatment)

YESNOHANDS-OFF ONLYN/A

Do you have any additional comments or questions before your session?

SOUND THERAPY

Sound healing sessions with Alchemy Crystal Singing Bowls®️ and other tools have a variety of effects that interact which each other and the body in ever expanding alchemies; clearing, activating, restructuring, rebalancing and healing. Through sound, vibration and intent they assist in clearing blockages, activating chakras and elevating our state of consciousness into higher layers of expanded awareness.

The sound and vibrational frequencies help us to open and release what is no longer serving. Crystal bowls help to remove blockages on an energetic and cellular level, by bringing them to the surface so we can release those emotions and continue on our healing journey of learning, expansion and love.

REIKI HEALING

Reiki is a healing technique that uses the universal life force energy to balance the subtle energies within our bodies, to support healing and contributes to balanced physical, mental, emotional, and spiritual states of being. During a Reiki session, your Reiki practitioner may lay their hands on your body or just over your body in a series of hand positions to deliver Reiki energy.

General Information

Energy medicine aims to help the flow of energy and remove blocks in a similar way to acupuncture or acupressure. Improving the flow of energy around the body can enable relaxation, relieve pain, speed healing, and reduce other symptoms of illness. With any Energy Healing session, you may feel a floating sensation, tingling or physical sensations, emotional release, increased relaxation, enhanced sense of balance, centeredness, and calm. The effects of Sound Therapy and Reiki are cumulative in which regular treatments can invite significant improvement. Regular sessions support well-being in every way. If you experience any pain or discomfort during this session, immediately inform the practitioner.

By Signing Below, you acknowledge the following:

I understand that Sound Therapy and Reiki is a simple, gentle, hands-on or hands-off energy technique that is used for stress reduction and relaxation.

I understand that Sound and Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment.

I understand that Sound Therapy or Reiki does not take the place of medical or psychological care.

I understand that Sound Therapy and Reiki can complement any medical or psychological care I may be receiving.

I also understand that the body as 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.

I understand that these services are not a substitute for medical treatment or medications. I am aware that diagnosis is not given and medication is not prescribed. I agree to check in with my trusted medical advisor if I am concerned or need further treatment.

I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that I may experience ‘healing reactions’ during the 24 to 48 hours following the services provided.

I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information communicated during these sessions are strictly confidential in nature and will not be shared with anyone without my written permission. I do, however, give the practitioner consent to use my case history and results without using my name. I understand that only the practitioner, Jennifer McClure 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, Jennifer McClure and the facility/location where the services are provided.

I agree to the terms and conditions set out by this consent form and certify that the above information is true and correct.

I agree to pay for distance sessions, should I request them.

In-Person Sessions: Payment will be exchanged the day of service.

*We Accept: Cash, Venmo, PayPal, Wise, or Credit Cards through Square. If using a credit card, we do charge a 4% convenience fee.

*Cancellation Policy*

We ask that you please reschedule or cancel at least 1 day (24 hours) before the beginning of your appointment.

Please sign below if you acknowledge the given information and give your consent to receive the treatment.*

** STUDIO ADDRESS **

Address will be EMAILED once form is submitted and received.