Reiki Consent Form

Consent Form - Reiki

Consent, Registration, and Consultation Form for Reiki Treatment with Claire Empson
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Having a picture of you helps me to tune into you before our session, and because I work alone from my private space it enables me to know who to expect through the gates, from a security perspective, thank you for your understanding
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB*
Emergency Contact Name*
Emergency Contact Phone*
Consent:

I consent to receive Reiki treatment from Claire Empson. I understand that Reiki is a complementary therapy and is not a substitute for medical or psychiatric treatment. I acknowledge that the practitioner will not diagnose conditions, prescribe medications, or interfere with the treatment plans of licensed medical professionals. I understand that the treatment involves gentle touch or no touch to channel universal life force energy, and I give permission for this. I release Claire from any liability or responsibility from any percieved outcomes or lack thereof
Signature*

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Date of Signing*

MonthDayYear
Date
1. Have you received Reiki treatment before?*

YesNo
If yes, please specify when and describe your experience:
2. Do you have any medical conditions or physical limitations that the practitioner should be aware of?*

YesNo
If yes, please specify:
3. Are you currently taking any medications or undergoing any medical treatments?*

YesNo
If yes, please specify:
4. Are you pregnant?*

YesNo
If yes, please specify which trimester/how many weeks:
5. Do you have any specific goals or intentions for this Reiki session?
6. Is there anything else you would like Claire to know before the session about your physical, emotional or mental state, or something else?
Declaration:

I declare that the information provided above is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform the practitioner of any changes to my health status or circumstances that may affect the Reiki treatment.
Signature*

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Date of Signing*

MonthDayYear
Date
Thank you for completing this form. If you have any questions or concerns, please feel free to discuss them with the practitioner before the session begins.
Privacy Statement
How did you hear about my Reiki services?:

Word of MouthSocial MediaOnline SearchAttended an EventOther
If you ticked 'other' please specify:
Have you paid?

Yes, I have already paidNo, I need to pay
What treatment did you pay for?

Reiki in person £75Distance Reiki £60
My Products*
prevnext( X )
ReikiIn Person 45 mins (1 hour appointment)
£75.00 Quantity

Distance ReikiDistance with initial contact over zoom or phone, 45 mins (1 hour appointment)
£60.00 Quantity

Total

£0.00
Do you consent to be added to my mailing list?

YesNo

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Consent Form - Reiki