Client Release Form
Fern
Life Center Reiki
Brian M. Dotson,
Reiki Master
Please print form and email to drifting.spirit@yahoo.com or bring it in to your first appointment. It is assumed that if you sumbit electronic payment that you have read and understand this disclaimer and the entirety of the form contained.
Name:_____________________________ Birth Day (M/D/Y)___________________
Mailing Address:
Street__________________________________________________________________
City:_____________________________
State:________________ Zip:_____________
Phone Numbers:
Daytime:_________________________
Cell:__________________________________
Emergency
Contact:___________________________________ Relationship:_________
E-Mail:_________________________
How did you hear about our
Reiki program? (Social Media, Flyer, advertisement, referral)
________________________________________________________________________
What do you hope to gain from
our Reiki Session?
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Optional: Describe
any injuries or significant medical problems you would like to make the
practitioner aware of.
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Also do you have a doctor’s clearance for any of the above
conditions?_____________________________________________________________________________________________________________________
Have you ever experienced Reiki, or received energy work?
______________________________________________________________________________________________________________________________________________________________________
AGREEMENT FOR STUDENTS
RELEASE AND DISCHARGE, ACCEPTANCE OF RESPONSIBILITYAND
ACKNOWLEDGMENT OR RISKS
Client Release Form
Fern
Life Center Reiki
Brian M. Dotson,
Reiki Master
I, the undersigned,
understand that the Reiki session given involves a natural hands-on method of
energy balancing for the purpose of emotional balance, stress reduction, and
relaxation. I understand very clearly that these treatments are not intended as
a substitute for medical or psychological care.
I understand that Reiki practitioners do not diagnose conditions, nor do they
prescribe medicines, nor interfere with the treatment of a licensed medical
professional. It is recommended that I seek a licensed health care professional
for any physical or psychological ailment I have.
Reiki may reveal areas of
emphasis, concern or even evoke emotional responses. If I choose to share
details, it is my choice to discuss with the practitioner. Feedback from the
practitioner is not intended as a substitute or replacement for licensed medical
or psychological counseling advice.
I understand that with my permission the practitioner will be placing hands on
me during the Reiki session.
My signature below indicated that I have read this entire document, understand
it completely, and agree to be bound by its terms. I am aware that I am giving
up important legal rights I might have. I sign of my own free will.
If I choose to submit Electronic payment it is assumed that I have read and understand this form.
DATE:_______________________
SIGNATURE OF
PARTICIPANT:__________________________________________
SIGNATUE OF LEGAL GAURDIAN OF
MINOR:_____________________________
