Disclosure & Consent Form

First Name

Last Name

Date of Birth

Confidentiality Statement: No information shared in our session will be discussed or shared with anyone else without your written consent or consent of your parent/guardian (for clients under 18). However, if your safety or the safety of someone else is at risk, I may contact emergency personnel.

Yes, I understand

I have questions regarding this

Reiki Disclosure: 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 reiki does not take the place of medical care.

Yes I understand

I have questions regarding this

Signature

I ackowledge that have read the above statements and consent to these services.

Thank you! Your response has been received.