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Saddha Reiki Consent Form
Saddha Reiki Consent Form
Contact Information
What is your first name?
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What is your last name?
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What is your email
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What is your phone number
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Please fill in your date of birth
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Who can I contact in case of an emergency?
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About You
Have you ever had a Reiki session?
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Describe your reason for scheduling this session (example: relaxation or a specific issue)
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Do you have any health concerns I should be aware of? (If yes, please elaborate)
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Are you taking any medications, supplements, or treatments? (you may list those here)
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Do you have any injuries, surgeries, or chronic pain areas I should be aware of?
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Do you have any allergies or sensitivities (e.g., to scents, essential oils, etc.)?
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Are you sensitive to touch? (If yes, please tell me more)
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Do you have any emotional concerns or areas of your life you would like to focus on during your session?
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Is there anything else you’d like me to know to support your healing journey?
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Consent to Treat
Do you give permission for Reiki to be performed as part of your wellness journey?
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Do you acknowledge that Reiki is a complementary therapy and not a substitute for medical treatment?
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Do you acknowledge that Reiki is a complementary therapy and not a substitute for medical treatment?
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All clients are required to agree to the following Release and Liability Waiver which is effective for all visits. By signing below, I acknowledge and agree that:
•I do not expect to be diagnosed of any medical conditions, prescribed medications, or provided medical treatments
•I do not expect to be diagnosed of any medical conditions, prescribed medications, or provided medical treatments
•The sole purpose of this session/s is for relaxation or stress reduction, also to balance, harmonize, release and heal on all four levels (physical, emotional, mental and spiritual)
•I assume sole responsibility for my own health and for the results of any sessions provided today and in future Reiki sessions that may affect my health in any way
•Treatment/s will not replace conventional medical diagnosis or treatment. I will continue taking medication prescribed by a licensed medical physician and will continue to follow his/her instructions
•Treatment/s will not replace conventional medical diagnosis or treatment. I will continue taking medication prescribed by a licensed medical physician and will continue to follow his/her instructions
•I assume sole responsibility for my own health and for the results of any sessions provided today and in future Reiki sessions that may affect my health in any way
•I release Saddha Reiki, from all legal liability during my participation in past and future treatment/s
Signature
Today's Date:
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