Client Intake
Thank you for taking time for YOU and scheduling your Reiki Session. Please complete the following form and sign the waiver below.

You will receive a reminder text before your appointment. It will contain helpful tips in order to benefit most from your session. Once scheduled refunded cancellations are not available, however a ONE TIME reschedule option through email or phone is available if more than 48 hours before your appointment.

Any questions please contact me!
Thank you ~ Brittani

blmcneill@hotmail.com 
402-201-1034
______________________________________________________________________________________________________________
Participant is aware of and understands the inherent risk and dangers associated with Covid 19, the Service, and agrees to assume all risk of and responsibility for personal injury or death, or damage to property arising from, based upon, or relating to my participation in the Service. I hereby agree, to the maximum extent permitted by law, to assume those risks and to release and to hold harmless Brittani Zahourek who (through negligence or carelessness) might otherwise be liable to me (or my heirs or assigns) for any and all claims, suits, damages, or losses, of any nature whatsoever, including, but not limited to, claims of personal injury, whether known or unknown, foreseen or unforeseen, arising from, or in any way related to, my participation in the Service. I have carefully read and freely signed this Release, and understand the terms used in it. I also understand that by signing this document, I may be giving up legal rights which I, or others claiming through me may have now or in the future. I agree that this Release is to be binding on my heirs and assigns. I understand that Brittani Zahourek is relying on my execution and delivery of this Release and allowing me to participate in the Service.

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Email *
First and Last Name *
Phone Number *
Birthday *
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How did you hear about our service?
Have you ever had a reiki session before? *
Required
What describes most what you would like to get from your energy healing session? *
Do you have any condition that might effect your ability to lie comfortably and relaxed on a massage table? If yes, please explain. *
On a scale of 1-10, with 1 being the least, select the number that represents your level of stress most days this month. *
Do you have any sensitivity to smells, such as incense or candles? If yes, please explain. Scents can be helpful during reiki but I am able to skip that step if needed for your comfort, it's your time and I want you to be comfortable!
I understand choosing an "I am ..." or "I have.." Statement before the session is extremely helpful. Example: I am aligned, I am Balanced, I have clarity, I am loved, I am connected. Whatever statement works for you, at this time in your life, choose your own or an example from above that you would like to achieve and have that in mind before we start. *
Required
Any other Concern/Question you'd like addressed ahead of time? *
I understand that Reiki is a simple, gentle, energy technique that is used for stress reduction and relaxation. *
Required
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. * *
Required
I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. * *
Required
I understand that Reiki can complement 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, complete relaxation is often beneficial. * *
Required
 I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. * *
Required
I agree to indemnify & hold harmless Healing not Broken & Brittani Zahourek of any account of any personal injury & property loss or damage. I hereby waive & release my practitioner from any & all liability present & future * *
Required
I understand in booking this session refunds will not be given. I know if its more then 48 hrs before, I can reschedule one time, by calling or by email. *
Required
 I understand if I have contagious symptoms, fever, illness or have been exposed to covid-19 positive, I am agreeing to complete transparency & will cancel or reschedule. If within 24 hours of appointment session will be done online instead. *
Required
I have read and understand the medical disclosure stated above. Please Electronic Sign and Date (xx/xx/xxxx) * *
Welcome to your healing journey!
A copy of your responses will be emailed to the address you provided.
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