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Energy Healing Form ୭˚⋆✴︎˚｡⋆

Introduce Yourself

Contact Information

Emergency Contact

What service are you interested in?

Additional add-ons

What is your intention?

Communication & Boundaries

Your comfort, safety, and consent are my priority. Is there anything that would help you feel more comfortable during your session, such as sensory preferences, communication preferences, or touch boundaries? You may request adjustments or withdraw consent at any time.

Please include any health concerns or specific conditions. Physically/Emotionally/Spiritually/Mentally

Current Health Support(s)

Are you taking any medications that may affect today's session?
Thank you for completing this intake form. Once your form has been submitted & your appointment request accepted, you will be contacted with further details to finalize your booking! <3

I agree to be part of the newsletter?

Confidentiality & Client Agreement

I understand that Reiki is a gentle, hands-on (or hands-near) energy technique intended to promote relaxation, stress reduction, and general well-being. I understand that Reiki practitioners do not diagnose medical conditions, do not prescribe medication, and do not perform medical treatment. Reiki is not a substitute for medical or mental health care.

I agree that I will seek or continue appropriate care from a licensed medical and/or mental health professional for any physical or psychological condition. Reiki may be used to complement care I am already receiving.

I understand that the body has natural healing processes, and that deep relaxation can support these processes. I acknowledge that long-term imbalance may require multiple sessions to reach a level of relaxation and support that is beneficial for my well-being.

I agree that I am solely responsible for my own health decisions and for any choices I make as a result of information shared in sessions. I understand and agree that sessions provided by Akhyra Renomeron do not replace conventional diagnosis or treatment.

I agree to continue taking any medications prescribed by a licensed healthcare professional and to follow that professional’s instructions, unless otherwise directed by my licensed clinician.

Both the client and the therapist agree to respect the confidentiality of all personal information and discussions that take place before, during, and after the session, except where disclosure is required by law.

Private Studio Policy

Reiki/Energy Healing sessions are provided in a private studio. To protect the privacy, safety, and security of the practice, you agree not to share, publish, distribute, or disclose the studio address or any identifying location details with any third party without the practitioner's prior written consent.

Only the scheduled client may attend the appointment. Guests, companions, and additional visitors are not permitted unless prior arrangements have been made and approved by the Practitioner.

Liability Waiver

I, the undersigned (“Client”), understand and agree that Reiki and related holistic services provided by Akhyra Renomeron (the “Practitioner”) are for relaxation, stress reduction, and general wellness. Reiki/Energy Healing is not a substitute for medical diagnosis or treatment and does not constitute medical or psychological care.

I acknowledge that I am responsible for my own health decisions and that I have been encouraged to seek appropriate licensed medical and/or mental health care for any physical, medical, or psychological concerns.

I understand that I may experience temporary effects from receiving Reiki/Energy Healing and related wellness services (including, but not limited to, relaxation, emotional release, fatigue, or changes in mood). I acknowledge that no specific outcome or result is guaranteed. I fully and freely consent to receive Reiki/ Energy Healing and any associated services offered by the Practitioner. I confirm that I am not relying on the Practitioner for diagnosis, treatment, or the management of any medical or mental health condition.

To the fullest extent permitted by law, I release, waive, discharge, and covenant not to sue Akhyra Renomeron, the Practitioner, and their heirs, successors, agents, employees, contractors, and associates (collectively, the “Released Parties”) from any and all claims, demands, causes of action, damages, liabilities, losses, costs, and expenses of any kind, whether known or unknown, arising out of or related to my participation in Reiki/Energy Healing and/or related services, including any alleged negligence by the Released Parties, except to the extent prohibited by law.

I agree to indemnify and hold harmless the Released Parties from any claims arising from my participation or from my breach of this agreement, except to the extent prohibited by law.

I further agree that this release is intended to be interpreted broadly and that it applies to all incidents occurring before, during, and after the Reiki and related services.

I acknowledge that I have read and understood this Liability Waiver, that I have had the opportunity to ask questions, and that I sign it voluntarily.

I acknowledge that I have read and understood this Liability Waiver, that I have had the opportunity to ask questions, and that I sign it voluntarily.

Deposit, Cancellation & Rescheduling Policy
Deposit: To secure your appointment, please send a $15 deposit via e-transfer. (this will be deducted from your total).
48-Hour Grace Period: You may cancel within 48 hours of booking for a full refund.
Late Cancellations: Cancellations made after this 48-hour window are strictly non-refundable.
Conduct & Termination
Professional boundaries must be maintained at all times. Should I engage in any form of misconduct or inappropriate behaviour, the therapist reserves the right to terminate the session immediately. In such an event, no refund will be provided.
Signature