Name: *

First Name

Last Name

Phone: *

Best way to reach you on short notice if needed.

(###)

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Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently under the care of a physician? *

Yes

No

Have you ever had a Reiki/Energy-work session before? *

Yes

No

Other (please use comments section below to describe)

Are you comfortable with hands-on touch during the Reiki session, or would you prefer a hands-off approach? *

Hands-on

Hands-off

Are you open to discussing any emotions or insights that may arise during or after the session? *

Yes, I am open to discussing

No

By checking this box, you agree to assume all risk of injury to yourself, and agree to discharge the practitioner from any and all claims or causes of action, known or unknown. *

I agree

I authorize Vibrant Zen to edit, alter, copy, exhibit, publish, or distribute photos, audio or video for any lawful purpose. *

I agree

*

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.

I understand and agree

I understand that full payment for services rendered, is required at the time of my visit unless other arrangements have been made. I further understand that in the case of extenuating circumstances, I may need to occasionally reschedule and will provide a minimum of 24 hours’ notice. If I miss my scheduled appointment without such notice, I will still be charged for that session.

I understand and agree

Today's Date: *

MM

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