Client Information

First Name*
Last Name*
Phone*
Date of Birth*

MonthDayYear
Address*
City*
State*
ZIP*
E-mail*
Gender

FemaleMaleWould rather not say
Referred by:*

FlyerAnother clientSmall street signsChiropractorPhysical TherapistLocal EventFacebookRadioNewspaperInternetYellow Pages
If another client or chiropractor referred you, please put their name
Have you ever experienced a reiki session before?*

YesNo
If yes, how recently?
1. Purpose of Reiki Session: The Client acknowledges that Reiki is a form of energy healing and is not a substitute for medical treatment or psychotherapy. The Client seeks Reiki services for relaxation, stress reduction, and general wellness.
2. Client's Health Status: The Client affirms that they are in generally good health and have disclosed any relevant medical conditions, physical ailments, or psychological concerns to the Practitioner prior to the session. The Client agrees to inform the Practitioner of any changes to their health status that may affect the Reiki session.
3. Nature of Reiki: Reiki is a non-invasive energy healing practice that involves the practitioner channeling energy through the practitioner's hands to the Client’s body. The Client understands that the Practitioner is not diagnosing, treating, or curing any medical condition and that Reiki is intended to support relaxation and well-being only.
4. Confidentiality: The Practitioner agrees to maintain confidentiality regarding any personal or health information shared by the Client during the course of the session, except as required by law.
5. No Guarantee of Results: While Reiki may promote relaxation, reduce stress, and support wellness, the Client understands and acknowledges that results may vary, and there is no guarantee of specific outcomes or immediate relief from physical or emotional conditions.
6. Liability Waiver: The Client agrees to release, indemnify, and hold harmless the Practitioner from any claims, demands, or causes of action, including but not limited to personal injury, emotional distress, or other damages, arising out of or in connection with the Reiki session. The Client understands that Reiki is intended to promote general well-being, but that it may not have a direct or immediate effect on specific health conditions.
7. Right to Discontinue: The Client understands that they have the right to discontinue the session at any time for any reason. The Practitioner also reserves the right to terminate the session at any time for any reason.
8. Informed Consent: By signing this Agreement, the Client affirms that they have had the opportunity to ask questions about the Reiki session and have received satisfactory answers. The Client consents to receiving Reiki services as described herein.
Consent to Treatment of Minor

By submitting this form, I hereby authorize the practitioner to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
Name of Parent/Guardian (if consenting for a minor)
Late/Cancellation Policy

Please arrive at least 5 minutes* before your scheduled appointment time in order to ensure a full massage session. * If you are a new client, then you will need to arrive 5-10 minutes early to go over paperwork. Clients arriving late will receive the rest of their appointment time and will be charged for the full scheduled appointment time. Clients arriving more than 15 minutes late will be rescheduled. You may cancel your appointment without charge 24 hours before your appointment. Cancellations less than 24 hours before session will be charged 25% of the scheduled service; less than 12 hours will be charged 50%. • If you do not call to cancel your appointment or do not show up for your scheduled appointment, you will be charged 100% for the scheduled service.
Sick Policy

Both practitioners and clients are vulnerable to infection from contagious illnesses. If you come in sick, it can worsen your condition. Please reschedule your appointment if you are feeling unwell. Clients with any of the following illness, or any other contagious illness not listed, will be rescheduled: Vomiting, fever, cold, influenza, diarrhea, measles, mumps, rubella, chicken pox, head lice, scabies, impetigo, meningitis, conjunctivitis, hepatitis A, thrush, polio, ringworm of the body, feet or scalp, meningococcal disease, and whooping cough.
I understand the building that Beni Massage and Wellness is located in a building that locks automatically in the evenings and on the weekends. I will wait for the practitioner to open the door for me and will not leave before my appointment time. I recognize if I leave before my appointment time that I will be charged a no show fee. Beni Massage and Wellness is located in a 2 story red brick building with green awning in front of the Megaton Brewery.*

I agree
By signing below, the Client acknowledges that they have read, understood, and agreed to the terms of this Reiki Session Agreement, Policies, and Liability Waiver above.*

I acknowledge and agree
Practitioner Signature

Clear
Signature

Clear
Should be Empty:

1. Purpose of Reiki Session: The Client acknowledges that Reiki is a form of energy healing and is not a substitute for medical treatment or psychotherapy. The Client seeks Reiki services for relaxation, stress reduction, and general wellness.

4. Confidentiality: The Practitioner agrees to maintain confidentiality regarding any personal or health information shared by the Client during the course of the session, except as required by law.

5. No Guarantee of Results: While Reiki may promote relaxation, reduce stress, and support wellness, the Client understands and acknowledges that results may vary, and there is no guarantee of specific outcomes or immediate relief from physical or emotional conditions.

7. Right to Discontinue: The Client understands that they have the right to discontinue the session at any time for any reason. The Practitioner also reserves the right to terminate the session at any time for any reason.

8. Informed Consent: By signing this Agreement, the Client affirms that they have had the opportunity to ask questions about the Reiki session and have received satisfactory answers. The Client consents to receiving Reiki services as described herein.

Consent to Treatment of Minor

Late/Cancellation Policy

Sick Policy