Reiki Intake & Waiver Form
Purple Phoenix Wellness – Energy Healing Services. This form is designed to help us understand your energetic needs and support you in receiving the most aligned Reiki healing session.
Full Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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example@example.com
What are you hoping to receive from your Reiki session?
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Have you received Reiki before?
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Yes
No
What emotional, physical, or spiritual concerns are you currently experiencing?
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Do you have any diagnosed medical conditions or mobility concerns that we should know about?
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Do you prefer a specific area of focus (emotional balance, physical healing, grounding, chakra clearing)?
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Would you like crystal healing and a 5 point alignment included?
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Yes
No
Open to intuition
Would you like post session insights or feedback after the session?
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Yes
No
Confidentiality & Consent Waiver
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All information shared will be held in confidentiality and used solely for the purpose of providing Reiki services through Purple Phoenix Wellness. I hereby give my consent to participate in this in-person, virtual or distance Reiki Treatment Session and understand that the services provided by my chosen Reiki Practitioner are intended to provide relaxation and reduce stress. I understand completely that the services provided during this Reiki Treatment Session are in no way a substitute for traditional medical treatment or advice. I am fully aware that my chosen Reiki Practitioner will not offer any diagnosis or recommend any Medical Treatment or Prescribed Medication. I understand that I must continue to have regular medical check-ups as part of my overall personal health care plan; and I should contact my own certified and licensed medical physician/doctor/health care professional for any physical or psychological ailments or concerns that I may have in order to get proper medical advice. I agree and understand that my participation in this Reiki Treatment Session is voluntary and that at any time during the Session I can choose to end my participation. I also understand that I may experience 'self-healing reactions' during the 48 hours following the Reiki Treatment Session. I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during or after these sessions is strictly confidential and will not be shared with anyone without my written permission. Finally, I understand that by providing this informed consent I am assuming full responsibility for participating in this Reiki Treatment Session and I hold harmless both my chosen Reiki Practitioner and the facility/location where the services are provided. I agree to the terms and conditions set out by this In Person Reiki Treatment Consent Form and certify that the above information is true and correct. I understand that the Reiki session I am receiving through Purple Phoenix Wellness is provided by a certified Reiki Master Teacher and is intended solely as a supportive, non-invasive energy practice. I acknowledge that: - Reiki does not diagnose, prescribe, or treat any illness or condition. - I am responsible for my own health and well-being before, during, and after the session. - I have disclosed any relevant physical or emotional concerns that may impact the session. - I release my practitioner (Purple Phoenix Wellness) from any and all claims, liabilities, or damages that may arise from my participation in Reiki services. I also understand that Reiki is most effective when approached with openness and intention, and that results may vary based on personal experience.
Signature
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Date
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Month
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Day
Year
Date
Submit
Submit
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