Emerge Reiki Intake & Consent Form
Sign in to Google to save your progress. Learn more
Name *
Phone *
Email *
Address (optional)
Emergency Contact *
If you are currently under the care of a physician please provide their name.
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? *
Please provide your preferred day(s) & time(s) for a session *
Do you have any specific healing intentions or any areas you'd like to focus on? *
CONSENT
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 *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy