Reiki & Energy Healing Client Consent Form
Los Angeles, CA
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact (optional)
How did you hear about us?
Health Information (Confidential) - Please check or list any that apply
Heart condition
High/low blood pressure
Diabetes
Epilepsy or seizures
Cancer or history of cancer
Pregnant
Currently under medical treatment
Other (please specify)
If you selected 'Other' in Health Information, please specify.
Are you currently receiving any other forms of energy healing, therapy, or bodywork?
Yes
No
If yes, please describe.
About Reiki & Energy Healing
Consent & Acknowledgment - I understand that:
Reiki practitioners do not diagnose conditions or prescribe medication.
Reiki is a complementary therapy and should not replace medical or psychological care.
Sessions may include light touch or can be conducted hands-off upon request.
Any information shared is strictly confidential.
I am participating voluntarily and accept full responsibility for my well-being during and after sessions.
Client Signature
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Practitioner Signature
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Optional Media Consent - Please select one:
I give permission for photos or short clips (with my consent at the time) to be used for social media or promotional purposes.
I prefer not to have any photos or recordings taken.
Client Initials
Submit
Should be Empty: