Reiki Consent Form

Reiki Consent Form

Please complete and return or print and bring to the session.
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
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:
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, essential oils 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.
Practitioner Name

First 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 but will be conducted in a professional and respectful manner.

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.
Client Signature

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Date Signed

MonthDayYear
Date
Should be Empty:

Reiki Consent Form

Client Information

Health Information