Intake and Consent

First and last name: Phone number: Mailing Address: Provide email to be added to our mailing list. Occupation: Emergency Contact Name: Emergency Contact Phone Number: How did you hear about us? What do you hope to accomplish with this Reiki session? What are your common areas of pain or tension? Have you ever had any accidents or surgeries? What would be a sign to you that you are feeling better? Do you have any concerns or is there anything else we should know?

Informed Consent - I hereby voluntarily request and consent to receive Reiki services from Karen Peters of A Joyful Balance Reiki.

I understand and acknowledge that no guarantees have been made to me as to the effect of such services.

I further understand and acknowledge that in no way are these services meant to be construed by me as the diagnosis or treatment of disease, but rather as an aid to balancing my energy and to possibly improving my general wellness.

I understand that I may refuse any and all services at any time during my first session or during subsequent sessions.

I understand that Reiki is not a substitute for medical treatment or medications, and it is recommended that I concurrently work with my doctor or primary caregiver for any condition I may have. I am advised that if I am sick, I should consult my doctor. I am aware that my Reiki practitioner does not diagnose illness or disease and does not prescribe medication.

lf I experience any discomfort during the session, I will immediately communicate that to the practitioner so that treatment can be adjusted.

I am 18 years of age or older.

Please type, I agree to A Joyful Balance Reiki's consent form followed by your first and last name

Agreement:

Please take a moment to complete our intake form

Please take a moment
to complete our intake form