Client Intake 10/10/2025 Anniversary Group Session
500 North Main Scribner, NE

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

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. Otherwise distant reiki will be provided at the same time as the event, no action needed by you, just awareness of the reiki being sent at the time of the event as energy works where ever you are.

Any questions please contact me!
Thank you ~ Brittani

hello@healingnotbroken.life
402-201-1034


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Email *
First and Last Name *
Phone Number *
Birthday (xx/xx/xxxx) *
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 affect your ability to lie comfortably and relaxed on a yoga mat or blanket? 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 ..." Statement before the session is extremely helpful. Example: I love that I am aligned, I love that I am Balanced, I love that I am worthy, I love that I am loved, I love that I am connected. Choose a statement that works for you, at this time in your life, and you would like to be the focus for your session, 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 Masters 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 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 have read and understand the medical disclosure stated above. Please Electronic Sign and Date (xx/xx/xxxx) * *
Session is $30, please *Select* if paying upon arrival or before. So that your spot can be held. This is an honor system and if you sign up and can't attend please let me know 48 hours before event if possible, thank you!
Welcome to your healing journey!
A copy of your responses will be emailed to the address you provided.
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