This Form Requires A E-Signature. By Typing Your Name In The Box Above You Understand That It Is Just As If You Signed The Form In Person. By signing you understand that Reiki is a simple, gentle, hands on energy technique that is used for stress reduction and relaxation. You understand that Reiki practitioners do not disclose conditions nor do they prescribe or perform medical treatments, prescribe substances, nor do they interfere with the treatment of licensed medical professionals. You understand that Reiki does not take the place of medical care. It is recommended that you see a licensed medical professional for any physical or psychological ailments. You understand that Reiki may compliment medical and psychological treatments you may be receiving. You also understand that the has the ability to heal itself and to do so complete relaxation is often beneficial. You acknowledge that long term imbalances in the body may require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

Privacy Notice

No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if under 18 years old.

Health History Inventory Form

Please Check The Box For The Items That Apply To You

Have You EVER Been Diagnosed By A Health Care Practitioner For Any Of The Following?

Please Check The Box If You Have Experienced Any Of The Following In The PAST 3 MONTHS