REIKI TREATMENTS — INTAKE FORM

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Name
Date
Date
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Phone
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Address
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DOB

Reiki practitioners are not doctors and do not diagnose or treat for a specific illness or prescribe or adjust medication. Reiki is not a substitute for medical or mental treatment, but is a complement to most types of therapy. By pressing SUBMIT I give my consent to a Reiki session. I understand I may discontinue a session or sessions at any time. If I have been diagnosed by a licensed health professional as having any disease, injury, or mental condition, I understand I should inform the person who made this diagnosis about the sessions I will be receiving, and whether or not I intend to discontinue any treatment or therapy which had been previously ordered, prescribed or recommended by a licensed health professional. I understand that by discontinuing any such treatment or therapy, I assume responsibility for any negative outcome resulting from discontinuing that treatment or therapy.