I hereby acknowledge that I am voluntarily requesting Reiki therapy session(s) with the primary intention of promoting relaxation, stress reduction, and overall health and well being. *

Yes

No

I am aware that Reiki practitioners do not provide medical diagnoses, prescribe medication, perform medical treatments, or interfere with the treatment plans of licensed medical practitioners or other healthcare professionals. *

Yes

No

They function as channels for energy flow, assisting in healing by introducing this energy into my physical and ethereal body. *

Yes

No

Reiki therapy is not a replacement for medical care or medication. If necessary, I will seek the consent of my healthcare provider before proceeding with Reiki sessions.* *

Yes

No

Participation in the session is entirely voluntary, and I have the right to terminate the session at any time. *

Yes

No

My safety and care during the session are primarily my responsibility. *

Yes

No

Reiki therapy is a complementary approach to the medical care I may be receiving. I commit to informing my practitioner of any significant changes in my health before future appointments. *

Yes

No

I acknowledge that the human body possesses the innate capacity to heal itself, and achieving a state of deep relaxation often aids this process. I understand that chronic imbalances might necessitate multiple sessions for the body to reach the required *

Yes

No

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(Cont) level of relaxation for self healing. The Reiki practitioners facilitate these sessions at my request and are not liable for the sessions outcome. *

Yes

No

I comprehend that there is no guarantee of specific results from the Reiki therapy provided. *

Yes

No

I have read, understood, and completed this form to the best of my knowledge. I accept full responsibility for my decision to receive Reiki therapy. I will promptly communicate and discomfort experienced during the session to allow necessary adjustments. *

Yes

No

I release my practitioner from any responsibility and liability for any circumstances that I may perceive as being associated with this healing session. *

Yes

No

Have you ever had a Reiki session before? *

Yes

No

If yes, for what purpose?

What do you hope to accomplish with this Reiki session?*

Do you take medication on a regular basis? *

Yes

No

If yes, please list medications and the conditions they’re addressing:

Are you pregnant? *

Yes

No

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