Client Consent & Information Form

Name *

First Name Last Name

Preferred pronouns

D.O.B

Month Day Year

Mobile No. *

Email *

example@example.com

Do you want to be added to my mailing list? *

Yes No

Address

Street Address

Street Address Line 2

Town County

Post Code

What are your goals for receiving treatment?

Pain relief Relaxation Addressing a trauma Improve Confidence & Build Self Esteem Other

Medical History. Please give details of medical conditions in the last 5 years.

Are you pregnant?

Yes No

Your height and weight (approx.)

Are you able to walk up/down stairs?

Are you able to get up/down to/from ground level comfortably?

Are there any injuries, surgeries, or recent health conditions that you feel the need to share?

Do you have an aversion to any of the following being used during your treatment?

Crystals Candles Incense Essential Oils Shamanic Rattle Shamanic Drum

I acknowledge that the practitioner has fully explained (in advance of my session) the treatment and the procedures involved.
All information disclosed during consultations/treatments shall remain fully confidential. If the practitioner felt obligated to break confidentiality for legal or safety reasons (for example you are about to cause harm to yourself or others) they would need to explain why.
I have completed the information above and have listed all known medical conditions and physical limitations. I will inform the practitioner of any changes in my physical health, medications, treatment, recent injuries, skin conditions or areas of concern before each treatment.
I acknowledge that reiki and any shamanic treatment(s) are not meant as a substitute for medical advice and treatment. If receiving treatment for a medical condition from your GP or hospital, you should inform all parties concerned that you are receiving reiki/shamanic healing treatments.
Should you suffer from any condition that requires a doctor’s permission prior to treatment but you chose not to obtain that permission, you will not hold the practitioner liable for any consequences related to that condition that may result from the treatment. Complementary therapies do not take the place of conventional medical treatment. If you are concerned about a serious, urgent condition, please see your GP.
A £25.00 non-refundable deposit (for reiki) and a £30 non-refundable deposit (for shamanic healing) is required to secure your booking and 72 hours (minimum) is required for cancellation of your appointment. Anything less than this will require either 50% (48 hours) or 100% (24 hours) of the cost of the treatment.
Treatment involves physical touch without the need to remove clothing (apart from shoes).
Respect for personal body privacy will be maintained at all times.
The practitioner reserves the right to refuse treatment if she feels physically unsafe, disrespected or abused.
I consent to my personal details to be used in line with the administration of my therapy and appointment. This information will be stored securely and is only accessible to the practitioner in line with his/her work.
I comply with the provisions of the Data Protection Act 1998. I consent to the practitioner storing my special category data (medical conditions) in line with the administration of my therapy and appointment. This information will only be passed on to a medical professional in an emergency situation.
I have read and understood the above and wish to proceed with the treatment.

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

Clear

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