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Canadian Reiki Association Client Information Form 

 I understand that Reiki is a stress reduction and relaxation technique. I acknowledge that sessions administered are only for the purpose of helping me relax and to relieve stress. Reiki Practitioners do not diagnose conditions, nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a licensed physician, or licensed health care professional for any physical or psychological ailment or condition I may have. 

I also understand the body has the ability to heal itself, and to do so complete relaxation is often beneficial. Long-term imbalances in the body require multiple sessions to allow the body to reach the level of relaxation necessary to bring the system back into balance. I understand and believe that self-improvement requires commitment on my part, and that I must be willing to change in a positive way if I am to receive the full benefit of Reiki. 

I acknowledge my commitment to my self-improvement process. I recognize that a Reiki session program must be followed to be truly effective, just as prescribed medication is only effective if taken as directed. 

*Note: Portions of this form originate from www.reiki.org with permission from the ICRT 

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Email *
Name *
Date of Birth *
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Address *
City *
Phone Number *
Doctor's Name *
Doctor's Phone Number *
Are you currently taking any medications?  *
Required

If yes, what are the medications for (ie: heart, diabetes, high blood pressure etc.)? 

Are you currently under the care of your Family Physician or Specialist? 

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Required
If yes, please elaborate 
Are you currently receiving other alternative treatments?  *
Required
If yes, what type ie: Homeopathy, acupuncture etc? 
Do you or have you ever suffered from seizures of any sort?  *
Required
If yes, please elaborate
Are you OK with being touched “appropriately” during the Reiki session or do you prefer not to be touched at all?

*Inappropriate touch of any kind by the Reiki practitioner or the client is a breach of the Reiki Code of Ethics* 

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Required
Do you have any concerns you wish to discuss before the Reiki session begins?  *
Required
Signature - Sign the waiver by typing your full legal name:  *
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