Have you ever had a Reiki session before?

Are you comfortable with light touch during your Reiki session? Y / *Please note that a "hover" method applies to all "bathing suit" areas and is non-negotiable. Please indicate if you prefer a completely hands-off treatment by choosing "N" above.

Are your feet or any parts of your body particularly sensitive to light touch?

What are your top three health priorities?

I Iunderstand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. understand that Reiki practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment. I understand that Reiki does not take the place of medical or psychological care. I understand that 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.

Print name of person signing: (If client is a minor a parent or guardian must sign)

Privacy Notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.

Consent to Services & Policies

Reiki is a gentle, complementary, alternative, energy-based approach to health and healing that can assist in bringing a body to its natural ability to restore health. We do not diagnose. prescribe or treat disease, we re not physicians and do not hold a medical license. We are certified to provide Reiki; documentation is available upon request. Reiki is nota substitute for diagnosis or treatment from a qualified health practitioner for illnesses, injuries, or other medical conditions.

Additional information on Reiki and all of our healing services are available on our website at http://the-mind-body- soul-connection.com

Confidentiality/Client Rights: Your experiences during our sessions are confidential, and you have a right to view your files upon written request. Confidentiality is subject to the following exceptions:

1.You may instruct me to release information to other health care practitioners in writing.

2.I may release information if subpoenaed or otherwise legally obligated or reasonably allowed to do so (Including circumstances where there is clear and imminent danger to yourself or another person

Cancellation and No-Show Policy Cancellations Please be advised that cancellations made up to 24 hours before a scheduled appointment via call or text to practitioner will be processed without a penalty.

Cancellations made 24 hours or less before an appointment will be subject to a charge of half of the cost of your scheduled service. For example, if your scheduled visit was $75, your cancellation fee would be $37.50. You will be asked to pay the cancellation fee prior to booking your next appointment. If we cancel an appointment with less than 24 hours' notice, a new appointment will be scheduled without penalty to the client and will be discounted for 1/2 of the visit cost.

No Shows If you do not show for your appointment and do not call or notify your practitioner at all, you will be subject toa charge up to the full amount of your scheduled visit cost and required to put a credit card on file or pay for future visits in advance of scheduling.

'We understand that emergencies arise, please communicate with your practitioner ASAP in these cases. You may be asked to put a credit card on file or pay in advance for future visits.

Minor Treatments A parent is required to be present for all visits with a child age 16 or under. For any child who is 16 or older, the parent must sign a waiver in advance allowing the child to attend the treatment without the parent present. Page 1

If this isn't possible, please work with your practitioner to discuss your options. We have this policy in place to protect your child as well as the practitioner.

Billing At this time, our services are not covered under insurance. All payments will need to be paid at the time of, or prior to the visit. A receipt can be provided at your request for reimbursement from Insurance or HSA accounts.

We accept payment in cash, Venmo, or credit/debit card. Receipts will be provided upon request and emailed to the customer's email address on file.

ACKNOWLEDGEMENT, CONSENT, CLIENT PRIVACY RIGHTS, LIABILITY WAVIER

Ihave read and understand the above disclosure regarding the services offered by The Mind-Body-Soul Connection, LLC. We have discussed the nature of the services to be provided including information that Reiki is a holistic complementary and alternative energy-based approach that is accomplished using light contact and/or non-contact options.

I understand that my practitioner is not a licensed physician and that Reiki services are not licensed by the State of New Hampshire. I understand it is my responsibility to maintain a relationship for myself with a medical doctor, if so desire. I further understand that the above named is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies. I have read and understand the above disclosure regarding privacy policies and confidentiality, and that experiences during these sessions are confidential, but subject to the usual exceptions.

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Jessica Gurney, and The Mind-Body-Soul Connection, LLS against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s) or any advice received based on the practitioner's personal experience.

I have been informed that my Reiki Practitioner will neither diagnose nor prescribe for any condition that I might have nor does he/she make any specific claims regarding results from the Reiki sessions that I receive.

My questions have been answered to my satisfaction regarding my Reiki Practitioner's background, a Reiki session, and what I might expect from this session. I fully consent to use the services offered by signing below:

By signing below, I agree that I have read and understand the information provided in the Consent to Treatment and Policy form.

This form does not expire but may be updated at any time. All policies and procedures are updated on the website.