Reiki & Healing Form — ELAINE ABILI

REIKI & HEALING: TREATMENT FORM

Client Treatment Record Form

Name

First Name

Last Name

Contact number

(###)

###

####

Address

Occupation

Date of Birth

YYYY

Gender and Pronouns (Optional)

Why would you like a Reiki Treatment and what are your expectations today?

Have you had any previous Reiki Treatments with other Practitioners?

Yes

Did you experience any problems during that or those Reiki session/s?

If yes, please give more detail

Where did you first hear about Elaine?

Date of booked session

YYYY

Your Medical History

Please note that although I am not a qualified medical professional and have no formal medical training, I am required to ask you about your medical history in case of an emergency.

How would you describe your general state of health?

Please tell me about any health issues e.g. allergies, asthma, major surgery, heart attack, high/low blood pressure, asthma, under/over-active thyroid, Multiple Sclerosis, rheumatoid arthritis etc. and any issues that may affect your ability to lie down during a treatment session.

Consent Form for Reiki Treatment

I have been advised that if I suspect I may have a medical condition, I should seek help from a qualified Medical Practitioner. I have been advised that if I take any Prescription Drugs, I must first consult my GP/Consultant before stopping or altering my dosage. I am over 16 years of age. The information I have given is true to the best of my knowledge and belief and I have not withheld any important relevant information that could affect my Reiki Treatment. I understand that all information will be treated in the Strictest Confidence. The Practitioner has fully explained the Reiki Treatment and the procedures involved and allowed me to voice any concerns and ask any questions that I may have regarding my Reiki Treatment. I understand that due to the nature of the treatment there will be touch involved using hands to pass energy. I confirm that the details given by me to the Practitioner are correct and that if any of the personal information changes, then I accept that I must inform the Practitioner before my next Reiki Treatment. I have had the opportunity to ask questions regarding the above and I am willing to proceed with the treatment. By submitting this form you are willingly consenting to all of the above.