Emerge Energy Healing 
Intake & Consent Form
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Name *
Phone *
Email *
Address (optional)
Emergency Contact *
How did you hear about Emerge?
Have you had a Reiki session before? If so when was your last session?
Are you sensitive to fragrances (diffused oils, incense, etc)? *
In-person involves laying of hands, do you have any sensitivities to touch? *
Which session would you like? *
For an in-person healing, please indicate if you would like to schedule a time on a Monday in Petaluma, CA or a Wednesday or Friday afternoon in Sebastopol, CA. *
Do you have any specific healing intentions or areas you'd like to focus on? *
By signing/typing your name below, you agree to the following: I understand that Reiki is a simple, gentle, hands-on energy technique that is used for  stress reduction and relaxation. 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. 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. 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. 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.  
Sign/Type your name to consent *
Today's Date *
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