Canadian Reiki Association Client Information Form

Acknowledgement

I understand that Reiki is a stress reduction and relaxation technique. I acknowledge that sessions administered are only for the purpose of helping me relax and relieve stress. Reiki Practitioners do not diagnose conditions, nor do they prescribe substances, perform medical treatment, or interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment or condition I may have.

I also understand the body has the ability to heal itself, and to do so, complete relaxation is often beneficial. Long-term imbalances in the body require multiple sessions to allow the body to reach the level of relaxation necessary to bring the system back into balance.

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

Signed:

Date:

month/date/year

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Gender

Doctor's Name

Doctor's Phone Number

Are you currently under the care of your Family Physician or Specialist?

If yes, please elaborate:

Are you currently taking any medications?

If yes, what are the medications for? (Heart, diabetes, high blood pressure, etc.):

Are you currently receiving other alternative treatments?

If yes, what type (Homeopathy, acupuncture, etc.)?:

Do you or have you ever suffered from seizures of any sort?

If yes, please elaborate:

Are you OK with being touched "appropriately" during the Reiki session, or do you prefer not to be touched at all?

Do you have any questions you wish to discuss before the Reiki session begins?