Intake Form

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Intake Form

Name *

Email
*

Birthdate *

YYYY

Name and number for emergency contact
*

Have you had Reiki or other forms of energy healing before?
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Yes

Maybe

Other:

Have you practiced breathwork before? If so what kind/s?
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When was your last healing session?
*

Please list previous history of injuries, illnesses and surgeries.
*

Please list any medications you are taking and for what
*

What themes and stories are recurring in your life that you'd like to better understand?
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Do you have a particular theme you'd like to address in this session?
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Please list any areas of pain, discomfort, contraction, illness or injury within the physical body.
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CONSENT: I consent to a healing treatment for myself (or my minor child) and understand that services provided by the practitioner Lindsay Hopkins are intended to enhance relaxation and inner coherence and increase communication between my body and my emotions. I understand that Reiki is a simple and gentle energy technique used for the purposes of healing, this may be administered in person with hands on healing or through guided meditation and remote (at a distance) healing techniques. I understand that Breathwork is a 2 part breathing technique done lying down to create movement and release in the body and its energetic pathways.
*

Yes

I understand that healing sessions are not meant to diagnose conditions nor do they prescribe or perform medical treatment, nor do they interfere with the treatment of a licensed medical professional. I understand it is recommended that I also see a licensed physician or health care professional for any acute physical or psychological ailment I may have. I understand that Reiki, Bodywork and Breathwork are important co-treatments to any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so I acknowledge that long term imbalances in the body sometimes require time, patience and commitment in order to facilitate the level of support needed by the body to heal itself. I understand that participation is voluntary and that at all times I may choose to end my participation. I may experience ‘healing responses’ during the days to follow the services provided. Self-care suggestions will be provided. I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. *

Yes

I also understand that any information shared during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. I do, however, give the practitioner consent to use my case history and results without using my name or age. I understand that only the practitioner Lindsay Hopkins will have access to this intake in my file. *

Yes

I understand that some healing sessions may need to go past the 60 / 75 / 90 min chosen session time. On occasion the session may go 15-20 minutes over and you will be charged additionally if this is needed. Each additional 15 minutes will be charged at $25. It's very important we don't disrupt the healing work if something is still moving and there is no way to anticipate this ahead of time. *

Yes

I understand that by signing this informed consent I am assuming full responsibility for receiving services and I hold harmless both the practitioner Lindsay Hopkins and the facility/location where the services are provided. I acknowledge that an appointment with Lindsay requires 24 hours notice for a cancellation. If a session is canceled after that time I will incur the entire session fee. Sessions can be rescheduled in the case of an emergency but the fee will be due at the time of the initial session. Pre-purchased sessions must be scheduled and services received within 90 days of purchase and are non-refundable. I agree to pay for sessions before or at the start of the session. *

Yes

By writing my name below (as an electronic signature) I agree to the terms and conditions set out by this intake and consent form and certify that the above information is true and correct. *

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