Waiver for Reiki

Name:*

First NameLast Name

Phone Number:*

Please enter a valid phone number.

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email:*

example@example.com

Birthday:

Date

How did you hear about Fairy Lux Healing?

i.e. Event, Referral, Website, Search, etc.

Have you ever had a Reiki session before?*

YesNo

If yes, when was your last session?

Date

Do you have a particular area of concern?

Are you sensitive to perfumes or fragrances, etc?*

YesNo

If yes, which of these would you like for me to avoid?

Are you sensitive to touch? (For in-person sessions)*

YesNo

Is it okay for me to place my hands on your head, neck, shoulder, knees and/or feet? (For in-person sessions)*

YesNoOther

The following Release and Liability Waiver is effective for all visits.

I understand that Reiki is a gentle, hands-on (and/or hands-off) technique 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.

I assume sole responsibility for my own health and for the results of any sessions provided by Ellen Segarra aka Elle Sega, Fairy Lux Healing that may affect my health in any way. Treatment/s will not replace conventional medical diagnosis or treatment. I will continue taking medication prescribed by a licensed medical physician and will continue to follow his/her/their instructions. I release Ellen Segarra aka Elle Sega, Fairy Lux Healing from all legal liability during my participation in the Reiki treatment/s, as well as the locations where Ellen Segarra aka Elle Sega, Fairy Lux Healing offers Reiki. All information received by me from Ellen Segarra aka Elle Sega, Fairy Lux Healing is accepted with full knowledge that any action taken by me as a result of the information is my complete responsibility.

Addendum

I understand that from time to time, Reiki sessions may be facilitated by a student practitioner who is training under the guidance and supervision of Ellen Segarra aka Elle Sega, Reiki Master/Teacher and founder of Fairy Lux Healing. These student-led sessions are offered on a donation basis for the purpose of practice, learning, and service.

I acknowledge that I have been informed when a session is being facilitated by a student practitioner, and I consent to receive Reiki in this capacity. I understand that the student practitioner is not a licensed medical professional, and Reiki is a complementary energy-healing practice that does not diagnose, prescribe, or replace medical treatment.

I release and hold harmless Ellen Segarra aka Elle Sega, Fairy Lux Healing, and any student practitioners offering sessions under her supervision from any liability for decisions I make regarding my health and well-being.

Signature:*

Today's date:*

Date

Privacy Notice

No information about any client will be discussed or shared with any third party without written consent of the client.