Reiki Client Information & Consent Form
This is form is a confidential document and will be reviewed and filed as such. The following questions are to gather information to support the Reiki service.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently under the care of a medical professional ?
Yes
No
If yes, would you like a copy of your Reiki Session Documentation emailed to them? Please provide their name and email below if so.
Have you ever had a Reiki session before?
Yes
No
If yes, when was your last session?
How many previous sessions of Reiki have you had?
Do you have a particular area of concern?
Current Medications & Supplements with dosage :
Are you sensitive to perfumes or fragrances?
Yes
No
I understand that Reiki is an energetic treatment where palm healing/ laying on of hands is typically part of the session. I understand that I will not be touched in any sensitive areas and that Deirdra Vierra is a Master Practioner and can apply Reiki "remotely" within any distance I feel comfortable with.
*
I am comfortable with a hands on treatment.
I am comfortable with hands in close proximity( 2 to 5 inches) to my body , but not touching me physically .
I am sensitive to touch and would prefer to be worked on at a distance .
I would prefer to have my Reiki session done remotely so that I may be comfortable in my own environment .
I understand that Hallowed Haircraft Company is a multi service business and my session will be performed in a suite that is used for more than Reiki. Please indicate your preference so the space will be properly set up for your session when you arrive .
*
I would like to have a full body treatment laying down on a Reiki Table .
I would like to be reclined and would like my session to be performed at the shampoo area so I do not have to be laying flat .
I would like to be seated upright
(By Typing your name below your agree to the following statement) "I understand that Reiki is a simple, gentle, remote or hands-on technique that is used for stress reduction, relaxation, clarity and more. I understand that Reiki practitioners do not diagnose conditions nor prescribe medication. I understand that my body has the ability to to heal itself and it will do so in divine timing. I will acknowledge my body and world consciously to recognize any drastic or subtle changes in my energetic field. I understand that this modality is performed while I am fully clothed . "
*
If you wish, please share the reason for the session below. Share any Physical, Emotional or Spiritual needs I should focus on for the intention of the session.
Signature
*
Date :
*
Parent or Guardian Full Name if client is under the age of 18
Name
*
First Name
Last Name
Parent or Guardian signature if client is under the age of 18
*
Date
*
Submit
Submit
Should be Empty: