Reiki Treatment Consent Form

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Reiki overview

Reiki at FLY Counseling is practiced is a hands-off holistic health treatment with the use of crystals to encourage relaxation and healing. At times there may be light touching of your hands and arms and during the placement of the crystals. Reiki is practiced while the client is fully clothed, on a massage table. If at any time you feel discomfort, you may ask for the session to be stopped immediately (session can be resumed after problem is addressed). Sessions are most effective in silence, but sometimes it is necessary to voice what you are feeling, particularly for those unfamiliar with Reiki, in order to feel at ease. Please note, for serious health conditions please see a licensed medical practitioner. For such conditions Reiki is considered a complementary form of treatment.

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What are you looking for?Check all that may apply.

Stress relief (anxiety)

Relaxation

Pain relief

Healing from emotional trauma

Spiritual growth

Healing from past/current relationships

Other

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Please list any and all special health restrictions: physical or medical conditions, including allergies

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Women only: Are you pregnant?

YESNO

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If yes, when are you due?

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Briefly describe what you are hoping to gain from your treatment.(share any physical or emotional concerns)

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Consent to Reiki Treatment

I understand that I have the following rights with respect to Reiki Treatment Sessions :

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

2. The laws that protect the confidentiality of my medical information also apply to telemental health and in-person counseling; FLY Counseling has also extended this confidentiality to Coaching clients as well. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

3. Cancellations and 'No call, no show' FEES:

If you need to reschedule your booked session, you have up until 24 hours before the date of your scheduled session.

PLEASE NOTE: In the event of a 'no call, no show' on the date of your scheduled session, you will be assessed a flat rate of $25.

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Consent:* This field is required.

Yes

No

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Client Full Name* This field is required.

First Name

Last Name

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Date of Birth

Date

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Email

example@example.com

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Client Phone Number

Area Code

Phone Number

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Emergency Contact: Name, phone number, and relation to you

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Signature

Clear

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Date* This field is required.