Reiki Consent Form

Reiki Consent Form
Client Information
Name

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Date of Birth

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Address

Street Address

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Phone Number
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Email
example@example.com
Emergency Contact Name

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Phone Number
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Health Information
Please answer the following questions to the best of your knowledge:
Do you have any medical conditions or concerns that you believe may affect your ability to receive Reiki treatment? (e.g., heart conditions, epilepsy, pregnancy, etc.)

YesNo
If yes, please provide details:
Are you currently taking any medications or supplements?

YesNo
If yes, please list
Have you undergone any recent surgeries or medical procedures?

YesNo
If yes, please provide details
Do you have any allergies (e.g., food allergies, skin allergies, etc.)?

YesNo
If yes, please specify
Reiki Treatment Consent:

I understand that Reiki is a holistic healing technique and is not a substitute for medical or psychiatric diagnosis and treatment. I consent to receive Reiki treatment from the practitioner named below.
Lisa White Butler

First NameLast Name
Description of Reiki Treatment: Reiki involves the gentle laying on of hands or non-touch energy transfer to facilitate relaxation, stress reduction, and overall well-being. The practitioner may place their hands lightly on or above various parts of the body to channel Reiki energy. The treatment may involve physical touch and application of essential oils but will be conducted in a professional and respectful manner. If I, the client, am allergic to any specific oil, I understand, I must disclose this inormation to the Reiki Practioner.

Benefits of Reiki: Reiki is believed to promote relaxation, reduce stress, alleviate pain, and enhance overall physical and emotional well-being. However, individual experiences may vary, and there are no guaranteed outcomes.

Risks and Limitations: While Reiki is generally considered safe and non-invasive, it may not be suitable for everyone. Potential risks or limitations may include temporary discomfort, emotional release, or exacerbation of existing symptoms. It is important to communicate any discomfort or concerns during the treatment session.

Confidentiality: All information disclosed during the Reiki session will be kept confidential and will not be shared without your consent, except as required by law.

Deposit:  I, the client understand that a deposit is required to book the session and I am required to provide a 24 hour notice of cancellation or notice to reschedule or I will lose my deposit.

Liability Release:  I release the practitioner from any and all liability associated with my Reiki session. I assume full responsibility for my health and well-being and agree to consult my medical provider for any medical concerns.
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Reiki Consent Form

Client Information

Health Information