Reiki & Sound Consent Form

Consent Form - Reiki & Sound

Consent, Registration, and Consultation Form for Reiki & Sound 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 a Reiki and sound treatment from Claire Empson. I understand that both sound sessions and Reiki are complementary therapies and not 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 may involve the use of instruments such as gongs, singing bowls, drum, tuning forks, chimes, or other sound tools, along with Reiki energy healing through light 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.

I have read the contraindication information below regarding gongs.

Pregnant individuals, especially those in their first trimester, should avoid Gong Baths due to the intense sound vibrations that may disrupt the delicate stages of early pregnancy. As a precaution, expectant mothers should consult their healthcare provider before considering participation in a Gong Bath during any stage of pregnancy.

By booking and attending you are accepting responsibility for yourself.

Contraindications further information
Signature*

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Date of Signing*

MonthDayYear
Date
1. Have you received Reiki or a sound bath 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 & sound 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?
7. Do you have any sensitivity to specific sounds or frequencies?

YesNo
If yes, please specify:
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 or sound 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 & sound 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 & sound in person £75Distance Reiki with some sound £60
My Products*
prevnext( X )
Reiki & soundIn Person 45 mins (1 hour appointment)
£75.00 Quantity

Distance Reiki & some soundDistance 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

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

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Consent Form - Reiki & Sound