Reiki Consent Form

Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

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Phone Number

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Email

example@example.com

Emergency Contact Name

First NameLast Name

Phone Number

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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

Do you have a pacemaker or have diabetes treated with insulin injections?

YesNo

If yes, please provide details:

Are you currently taking any medications or supplements?

YesNo

If yes, please list

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, 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 NameLast 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.

Agreement: 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, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that any information perceived in a session may not be construed as a medical diagnosis of a current medical condition, as information has no time or space constraints, and could be of past, present or future importance. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have.

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.

Having read and understood the foregoing I request to receive hands-on Reiki treatment today. I agree that my practitioner is providing Reiki treatment for me at my request and I agree to hold my practitioner, and PIA a division of Bryson Taylor Inc, harmless of any intended or unintended result.

Client Signature

Date Signed

Date

Reiki Consent Form

Client Information

Health Information