Pet Client Intake Form

Pet Name

Pet Age

Address

City

State

Zip code

Phone

Format: (000) 000-0000.

Email

example@example.com

OK to share pet photo(s) prior to the session?

Would you like to be added to my newsletter?

If pet is taking any medications, please advise:

Is pet pregnant?

If yes, how far along?

Are there any concerns regarding medication or pregnancy?

If pet suffers from chronic pain, please advise (otherwise, enter N/A):

If there is anything that makes the pain subside or feel worse, please advise (otherwise, enter N/A):

Please check all that apply if your pet experiences or has experienced any of the following (otherwise, skip this section):

If your pet is currently undergoing veterinary care, please advise (otherwise, skip this section):

Has your pet ever had energy healing or Reiki performed before?

If yes, how long ago, and what was the outcome?

Has your pet ever had any other holistic or natural healing performed before?

If yes, what was it, how long ago, and what was the outcome?

What are your goals for this healing session? Tick all that apply:

Other

Confidentiality Statement:

Your privacy and the confidentiality of your information are paramount to me. I am fully committed to safeguarding any personal information you share throughout our professional relationship. Here is how we manage your information:

Confidentiality Commitment: Any information, whether written or spoken, shared during our interactions, will be held in strict confidence. I will not disclose your information to any third party without your explicit consent, except in situations where I am legally obligated to do so.

Limits to Confidentiality: While I prioritize maintaining confidentiality, it's important to recognize that there are legal and ethical boundaries. These situations may involve imminent harm to yourself or others, suspicion of child or elder abuse, or court-ordered disclosure.

Information Protection: I utilize appropriate security measures to protect your personal information. All electronic and physical records are securely stored and accessible only by me.

Record-Keeping: Any records maintained adhere to relevant laws and professional standards. Records are retained for a specified period and then securely disposed of.

Consent for Communication: By signing this form, you acknowledge and consent to the use of communication methods discussed and agreed upon during our sessions (e.g., phone, email, text messaging, video conferencing) for the purpose of our professional interactions.

Please don't hesitate to ask any questions or seek clarification about this confidentiality statement. Your understanding and agreement to these terms are crucial to our collaborative work.

Client's Acknowledgments and Waiver:

By affixing my signature below, I, the client (pet's owner), confirm that I have diligently and honestly completed this form and will promptly inform you of any changes. I acknowledge that energy healing is a natural, non-invasive approach aimed at enhancing my pet's overall health and well-being, and it should not be viewed as a substitute for urgent or essential veterinary care. I also recognize that Priscilla Daphney is not a licensed veterinary professional.

I understand that a Reiki session cannot replace the expertise of a licensed veterinarian. I acknowledge that Reiki Practitioners do not provide diagnoses, prescriptions, medical treatments, or interfere with veterinary care. I hereby agree that any pet health conditions or ailments will be managed by a qualified veterinary professional.

Pet Parent/Guardian's Signature

Date

Healer Acknowledgments:

By affixing my signature below, I, the Reiki Practitioner, commit to conducting the healing session with a genuine and loving intention, aimed at serving the highest and best interests of my client (pet). I have also provided my client's human (pet parent/guardian/caretaker) with guidance regarding what they can anticipate before, during, and after the session.

** Healer's Signature Only

Healer's Signature Only

** Healer's Date Only

Healer's Date Only

Disclosure:

• I am not licensed by the state of California as a healing arts practitioner, as supported by the California Health Freedom bill SB-577 https://californiahealthfreedom.com/about-us/our-bill/.

• I am not a licensed physician. I do not diagnose medical conditions, prescribe medications, or provide medical treatment.

• I do not make any claims of curing, treating, or preventing medical conditions. Reiki is not a replacement for conventional medical care, and individuals should consult their healthcare provider for any medical concerns.

• Reiki is a complementary alternative to the healing arts services that are licensed by the state of California and is not a substitute for medical treatment or diagnosis.

• SB-577 Legal Information: http://www.leginfo.ca.gov/pub/01-02/bill/sen/sb_0551-0600/sb_577_bill_20020923_chaptered.html