Sally Broadhurst Reiki Intake Form

Sally Broadhurst Reiki Intake Form
Name*

First NameLast Name
Address*

Address

Address Line 2

CityProvince

Postal Code
Phone Number
E-mail*
example@example.com
Date of Birth

MonthDayYear
Date
Emergency Contact*

NamePhone
Are you currently seeing any other health care providers? (Doctors, Chiropractors, Acupuncturist, Massage Therapists, Specialists, etc.):
How did you hear about me*
Referral*
Would you like a dose of wellbeing in your inbox? (no side effects, promise, just a semi-regular newsletter)*

YesNo

Health Information
Have you had a Reiki session before?

YesNo
Reason for your visit today/areas of concern and your goal for this session (example: relaxation, pain reduction, general wellbeing, improved sleep, increased vitality, stress reduction, other):
Do you have any medical conditions or information I need to be aware of:
Session Preferences:
Do you have any trouble with lying on your back for the entire session:

YesNo
Aromatherapy may be used in the treatment room - do you have any fragrance or other sensitivities:
Are you comfortable with light touch during your session - please indicate if you prefer hands on or hands off:

Hands onHands off

Reiki Informed Consent:
Understanding Reiki:
I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation.

I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment.

I understand that Reiki does not take the place of medical or psychological care.

I understand that Reiki can complement any medical or psychological care I may be receiving.

I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

Treatment Approach:
I understand that Reiki may involve light touch or hands placed just above the body. For in-person sessions, I can request no-touch at any time during the session.

For distance/online sessions, I understand this session will be conducted remotely, and I agree to be in a safe, comfortable location during the session time.

I agree to communicate openly with my practitioner about my comfort and experience during the session.

Privacy and Records:
A confidential health record will be maintained in accordance with Australian privacy legislation. My health information will not be released to third parties without my written consent, except where required by law. I have the right to access my health records upon request.

Cancellation Policy Acknowledgment:

I understand that in-person reiki sessions require advance payment to secure the space.

If you need to reschedule: Please give me at least 24 hours notice and I'm happy to reschedule at no charge. Rescheduling with less than 24 hours notice will forfeit the $25 room booking deposit.

If you need to cancel: Please give me at least 24 hours notice for a refund of your session fee minus the $25 room booking deposit (which I pay upfront to secure the space). Cancellations with less than 24 hours notice will forfeit the full session fee.

Consent:
I confirm that I have read, understood, and agree to the above terms. I have had the opportunity to ask questions and consent to this Reiki treatment.
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Sally Broadhurst Reiki Intake Form

Health Information

Session Preferences:

Reiki Informed Consent: