Name:
Email:
Phone #:
Best time of day to call:
Preferred date and time for appointment (include alternate option):
1] Who is this treatment for? If not for yourself, please include all names, and your relationship to the Reiki recipient(s). Has he/she/they given you consent to receiving this treatment?
2] Have you or the recipient ever engaged in other forms of holistic healing or complimentary healthcare (i.e. yoga, acupuncture, meditation, etc)?
If yes, please describe
3] Why are you interested in Reiki?
4] Describe the condition, situation or event for which you are requesting Reiki.
5] Even if the treatment is meant for say grievance over a pet, or to boost the memory of someone doing an exam, please give a brief medical history of the Reiki recipient, and include the current medication the recipient takes. Provide specific details. For example, in case of heart issues, indicate if the recipient has a pace maker. If you have cancer, where is it located and has it spread, etc. This information will assist your practitioner in creating the best treatment plan possible.
6] What are the usual symptoms of the condition/situation for which you want Reiki?
7] Describe your/the recipient's lifestyle in terms of smoking, drinking, eating, and exercise habits.
8] What emotional challenges are you currently working on (eg. as a result of your physical illness)?
9] Do you understand that I cannot guarantee any specific benefits you/the recipient might receive from treatment? Reiki goes where it's most needed and it's your body & spirit that decide how to use the Reiki energy for your highest good.
* Please read the below disclaimer note and indicate your understanding and agreement to this treatment relationship by printing out this form and including your signature below. In doing so, you are acting on behalf of the Reiki Recipient.
disclaimer:
"I freely acknowledge that I am fully aware that Allison Joy Faelnar is not a medical doctor, or any other kind of medical practitioner and she has not represented herself in any way as possessing any medical expertise or medical training whatsoever and has not prescribed, diagnosed or treated or recommend any particular treatment or medication or substance for me in respect of my injury, ailment or disease that I may possess.
I have not been cajoled, coerced, threatened or persuaded by Allison Joy Faelnar to undergo or partake in any particular treatment or medication or substance, and that I freely acknowledge that any unorthodox or unusual treatment or medication or substance that I may utilize is done with my full awareness and acknowledgment that it is of my own free will.
Further to accepting the explained treatment, I, the undersigned, for myself, my heirs, successors, executors, administrators and assignees, hereby release and forever discharge Allison Joy Faelnar, her associates, their heirs, and her heirs, successors, executors, administrators and assignees, from any and all actions, causes of action, claims and demands for or by reason of any damage, loss or injury, to person and property which heretofore has been or hereafter maybe sustained in consequence of any medication, substance or treatment which I may use or consume in any respect of and for any attempts by myself or anyone on my behalf to cause temporary or permanent relief from the symptoms of any injury, ailment or disease with which I have been or will be diagnosed."
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Signature
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