Reiki Session Consent Form
I hereby request and consent to Reiki treatment by Arlene, a Reiki practitioner.I understand that Reiki serves individuals with a wide range of complaints, including both acute and chronic healthcare issues. No guarantees concerning its use and effect are given to me.
I am over the age of 16 years old. The information I have given is true to the best of my knowledge, and I have no withheld any relevant information.
Yes
No
I have been advised that if I suspect I may have a medical condition. I should seek out help from a qualified medical doctor.
Yes
She did not.
I have been advised that if I take any prescription drugs, I must first consult my GP/consultant before making any alterations.
Yes
She did not.
I understand that all information will be treated in the strictest confidence.
I understand.
I don't understand.
The Practitioner has fully explained the Reiki treatment and the procedures involved.
Yes
She did not.
I understand that at all times, my personal body privacy will be maintained, I am not required to remove any clothing, except my shoes.
I understand.
I do not understand.
I confirm that the details given by me to the Practitioner are correct and that if any of the personal information changes, then I accept that I must inform the Practitioner accordingly.
Confirmed!
Not confirmed.
I confirm that the details given by me to the Practitioner are correct and that if any of the personal information changes, then I accept that I must inform the Practitioner accordingly.
Confirmed!
Not confirmed!
I understand that if there is an emergency, a worsening of my health condition, or a new ailment or condition arises, that I should consult a licensed physician.
I understand.
I do not understand.
I have had the opportunity to ask questions regarding the above, and I am willing to proceed with the treatment.
Lets do this!
Yeah, lets not.
I understand that the fee per session is donation based.
Yes
No
Signature
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Submit
Should be Empty: