Reiki Session Client Intake & Consent

Reiki Session Client Intake & Consent
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth

MonthDayYear
Date
Emergency Contact: Name, Phone, Email, Relationship
Please describe your primary reason for seeking treatment:
Please describe any current physical complaints or restrictions:
Please list any current or previous illnesses, injuries, or surgeries:
Please describe what would you like to achieve with this healing session:
Please indicate your current physical state

None = 0, Mild = 1, Moderate = 2, Severe = 3, Debilitating = 4
Presence of physical pain
Feeling of tension
Lack of flexibility
Fatigue or low energy
Feeling of stress/overwhelm
Interrupted sleep at night
Reiki therapy is provided to help clients with physical, mental, emotional, and spiritual issues. While many clients find relief with these therapies, no healing claims are made for any of them as everyone reacts differently.

At your initial meeting with your practitioner, you will work together to develop a Plan of Care to identify your treatment goals and frequency of sessions. Your Plan of Care will be reassessed to monitor progress in fulfilling your treatment goals after each visit. We appreciate the opportunity to serve you. Thank you for your consideration of our staff and other clients.
By signing below, I acknowledge that I understand and that I am informed that the practice of these therapies is considered safe. Although side effects are rare, they may include headaches, muscle soreness, light-headedness, dizziness, and/or nausea. I do not expect the practitioner to be able to anticipate and explain all risks and/or complications, and I wish to rely upon the practitioner to exercise judgment during the procedure.

By signing below, I acknowledge that I have read, or have had read to me, the above consent. I intend this consent form to cover the entire course of my sessions and for any future Reiki through Hospice SLO County that I may receive.
Signature

Clear
Should be Empty:

Reiki Session Client Intake & Consent

Please indicate your current physical state