Reiki Consent Form

Alternative Reiki Healing Services Informed Consent

I (the Client), understand that Heather Wright/Fitmind Wellness Solutions LLC (Practitioner) offers holistic therapies and non-traditional complementary interventions such as Reiki Energy Healing, Crystal Placement Healing, Essential Oil Aromatherapy and topical applications, healing gemstone jewelry, lifestyle coaching, and mindset coaching,all of which are intended to promote health and wellness, enhance relaxation, reduce pain, become relaxed and more comfortable with your own thoughts, letting go of tensions and apprehensions caused by stress, emotional barriers and physical /mental illnesses and offer a positive experience utilizing the concept of mind, body, and soul in treatment intervention.

Disclosure for Treatment
I understand that the Practitioner is a trained Wellness Professional, and is not a massage therapist, chiropractic doctor, registered nurse, registered medical dietitian, nor a medical doctor. I understand, the practitioner is not qualified to diagnose, treat, cure, prevent or assess any disease, disorder, or condition. I understand, the practitioner is not qualified to prescribe medication or provide medical nutrition therapy dietary plans.

I understand that the Practitioner can make wellness recommendations, and it is my responsibility to consult with my medical team prior to making any adjustments to my lifestyle, medications, or supplementation regimen.

I understand that holistic therapy interventions provided by the Practitioner are not a substitute for medical treatment, psychotherapy, or medications, and that it is recommended that I concurrently work with my primary healthcare provider for any condition I may have. I am aware that the practitioner does not diagnose illness or disease, does not prescribe medications, and cannot legally take the role of a medical doctor.

I wholeheartedly understand that following any set regime does not promise any form or level of cure for any specific (or otherwise) condition. I promise to abide by any warnings or contra-indications given to me through consultation if products and services are used.

I understand that I am under no obligation to follow any recommendations for treatment given.

Treatment Delivery

I understand that Reiki treatments may be provided via the following methods:

- in the Practitioner's office.

- In my home, hotel, or office.

- in an outdoor setting mutually agreed upon by Client and Practitioner.

- via distance transfer

Appointment Reservation and Cancelation Policy (General)

I understand that I must provide a $30 deposit via Venmo with the Practitioner to reserve my appointment. This amount will be applied to my total service invoice.
In the event that I cancel my appointment less than 12 hours prior to my scheduled appointment, i will be charged a $30 fee.

I understand that in the event that i re-schedule my appointment, that $30 fee can be applied to the total balance of the new appointment.

Unforseen challenges such as medical emergencies, illness, car trouble, etc. will be exempt of the cancelation fee at the Practitioner's discretion.

I understand that The Practitioner reserves the right to refuse exemption if the Client repeatedly cancels and reschedules on short notice with no valid challenge.

Medical Health, Medicines, and Conditions
I have informed the practitioner of all my known physical and medical conditions, and I will keep the practitioner updated of any changes. I will notify the practitioner should I become pregnant of if I am trying to become pregnant.

I have informed The Practitioner of any medications I am currently taking, and I know that it is my responsibility to inform The Practitioner of any changes in my health status, surgery history, or medication history.

Allergies

I understand that it is my responsibility to inform the Practitioner of any allergies that I may have to essential oils, scents, foods, herbs, flowers, lotions, etc. prior to any treatments.

Privacy and Records
I understand that I may share any of my PHI/medical records with the practitioner and they will be kept in a secure email or HIPAA safe Google Drive platform for storage. All of my records will be kept confidential and will not be released without my written consent.

Add-On Enhancement Services

Additional services such as healing gemstone placement, take-home healing gemstones, custom-made healing gemstone jewelry, custom-made essential oil diffuser blends & skin rollers, and candles are available as part of my healing recommendations but I am in no way obligated to purchase or use these items. I understand that these items will be offered to me at the Practitioner's discretion for the intention of enhancing my benefits from each Reiki session.

Nutrition & Lifestyle Services

I understand that the Practitioner may provide lifestyle recommendations to me to enhance the benefits of the Reiki treatments. I am in no way obligated to follow these recommendations, and the Practitioner highly recommends consultation with my medical team prior to applying any lifestyle or nutritional changes.

Mindset Coaching

I understand that spiritual mindset coaching is available to me upon offering of the Practitioner to enhance the benefits of my Reiki services. I understand that mindset coaching is not a form of psychotherapy and should not be used in place of mental health services for diagnosis or treatment.

Tarot and Rune Readings

These services are considered upgrades and not included in any treatment packages unless otherwise promoted or specified by the Provider.

Home Visits

I understand that I may request Reiki Healing services to be performed by the Practitioner in my home. All services will be performed in a private room in my home that is free of cigarette smoke, illegal drugs, vicious pets, or any other potential threat to the wellbeing of myself and the Practitioner.

I understand that I am to supply a space for the Practitioner to work, including a clean surface for them to work with, unless otherwise instructed by the Practitioner, in the event that they will be bringing their own treatment table.

I understand that if at any point the Practitioner does not feel comfortable with the environment, my behavior, or the inhabitants of my home, that they may leave upon their own free will, and, I (the Client), have the freedom to ask the Pracitioner to leave in the event that the behavior of the Practitioner makes me uncomfortable.

I understand that if I display malicious intent, whether verbal or physical, toward the Practitioner I may be prosecuted to the highest degree of the law in those violations.

I understand that in the event that I ask the Practitioner to leave, I will have to pay for the services rendered, if there were services rendered during the duration of their time in my home.

Home Visit Cancellation Policy

I understand that if i cancel my reservation less than 12 hours in advance, that I will be charged a $30 fee that is non-refundable, but should I re-schedule my appointment, this fee may be applied to the total session fee of my new appointment.

Safety and Personal Protection

I understand that the Practitioner has the right to carry personal protection as they are licensed to do so. I understand that I have the right to ask the Practitioner if they are in posession of a personal protection item, and ask to have the item placed in the room where both parties can see it.

Distance Healing Sessions

I understand that Distance Healing Sessions do not require any physical contact at all, as Reiki is a powerful healing energy that travels any distance, time, or space. This means that no phone call, text message, or video chat is required for the session, but the Practitioner may contact me after the session with feedback of their session and findings. I understand that I may be asked to provide a photo of myself, family member, item, etc. that I am requesting Distance Healing for as it helps the Practitioner to connect with them.

Treatment of Minors

I understand that If i am requesting the Practitioner to treat a minor, any child under the age of 18 years old, that this minor is my responsibility and i have legal guardianship over this child.

I understand that during the session I must be present in the room for the safety of everyone involved.

I understand that I am exposing my minor child to therapuetic methods offered by the Practitioner upon my own free will.

I have read and understand this consent to treatment. I have been informed about the risks and benefits of holistic therapy procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.

Treatment of Expectant Mothers

For the safety of the mother and the baby, NO use of essential oils, incense, or massage will be used for Reiki treatment sessions. Reiki PLUS sessions will also be shortened to 60-minutes in duration.
Consent for Treatment for Reiki

I, the undersigned Client, understand that the Reiki session given involves a natural hands-on method of energy balancing for the purpose of pain management, stress reduction, and relaxation. I understand that I can choose to not participate in a hands-on therapy session, but receive "hands-above" instead.

I understand very clearly that these treatments are not intended as a substitute for medical or psychological care.

I understand that Reiki practitioners do not diagnose conditions, nor do they prescribe medicines, nor interfere with the treatment of a licensed medical professional. It is recommended that I seek a licensed health care professional for any physical or psychological ailment I have.
Client Full Name*

First NameLast Name
Date of Birth:*
10-20-1990
IF CLIENT BEING SEEN IS A MINOR: Enter Legal Guardian's Name Below

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I understand that the practitioner will be placing hands on me or above me during the Reiki session. (Please choose an option)*

I am ok with hands on treatment.I am ok with hands above treatment only.I am okay with both methods of treatment.
Are you currently pregnant?*

YesNoUnsure
Do you have any respiratory conditions or sensitivity to smells?*

Yes, I am sensitive or have a condition. (No oils or incense will be used.)No, I am not sensitive or have a condition. (Oil and incense use will be discussed before use.)I prefer no incense or oil be used during my session.
SELECT:*

By checking this box and signing this box, I consent and understand that I may discontinue a session or sessions at any time. If a licensed health professional has diagnosed me as having any disease, injury, or other physical or mental condition, I understand that I should inform the person who made the diagnosis, about the session I will be receiving, and whether or not I intend to discontinue any treatment or therapy which had been previously ordered, prescribed or recommended by a licensed health professional. I understand that by discontinuing any such treatment or therapy, I assume responsibility for any negative outcome resulting from discontinuing that treatment or therapy.
HOME VISIT LOCATIONS

If you are having Reiki in your home or office, provide the address for each
HOME ADDRESS*
OFFICE ADDRESS
If treatment will be in your office or alternate address than your home, please list the address
Nature of Reiki Treatments

I understand and believe that self-improvement requires commitment on my part, and that I must be willing to change in a positive way if I am to receive the full benefit of a Reiki treatment.

I acknowledge my commitment to my self-improvement process. I recognize that a Reiki treatment program must be followed to be truly effective, just as prescribed medication is only effective if taken as directed.

I acknowledge that the practitioner neither claims nor implies that any instruction, advice, counsel, suggestions, recommendations, services or products she or her representatives provide, whether in person, by mail, by telephone, or by internet, will cure, treat, prevent, or mitigate any disease condition; but are provided solely for the purpose of increasing energy, supporting the natural function of body systems and otherwise improving general health and fitness.

I understand Reiki is a stress reduction and relaxation technique that promotes healing on all levels when practices as hands-on ( as well as off-the-body in person or over distance) method that is always gentle, gentle-touch and relaxing.

I understand that there are no adverse effects to Reiki and no risk in regards to this service. I understand that I may feel a slight change of temperature in areas where hands are place and possible minor to little discomfort in areas due to healing properties but will receive a state a relaxation from process . I understand that I may be consumed with emotions during session which is common for some clients to encounter.

Reiki does not cure disease and is not intended to be the primary treatment for any health problem, but rather is a complementary therapy meant to support other treatment that is ongoing.

Reiki is not recommended for broken bones, acute pain, or any condition requiring immediate medical attention.

By providing my signature below, I am acknowledging that I will abide by all of the aforementioned terms. I am also acknowledging that I am participating in the Reiki Energy Healing Services and other items offered by the Practitioner at my own risk.

HOME VISIT LOCATIONS