Reiki Consultation and Consent Form

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Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently (or possibly may be) pregnant or breastfeeding? *

Do any of the following apply to you? Please tick all that apply.

Receiving Chemotherapy Receiving Radiotherapy Fitted with a pacemaker Epilepsy Diabetes

Do you have any other medical conditions? *

Please list: *

Have you had any significant accidents, injuries, surgeries, seizures etc.? *

Please list: *

Consultation

Are you currently receiving other alternative treatments (e.g. Homeopathy, Acupuncture etc.)? *

Please specify: *

Have you had a Reiki session before? *

How was your experience? *

How many previous sessions have you attended? *

Reiki involves a gentle, appropriate, hands-on technique. Are you ok with light touch? *

Do you have any difficulty lying on your front, back or side? *

Please specify: *

Do you find time to relax or meditate? *

How often? *

Do you find time to exercise? *

How often? *

What type of exercise do you do? *

How many hours of sleep do you get in an average night? *

Please rate your quality of sleep (1 being the worst, 5 being the best): *

Please rate your level of stress: *

Do you have a particular area of concern you would like to focus on? *

Please specify: *

What would you like to get out of the Reiki session? *

Do you have any concerns you would like to discuss before the session? *

Please specify: *

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Treatment Information

What is Reiki?

The word “Reiki” means “mysterious atmosphere, miraculous sign.” It comes from the Japanese words “rei” (universal) and “ki” (life energy).

Reiki is a type of energy healing. Energy healing targets the energy fields around the body. Energy can stagnate in the body where there has been physical injury or possibly emotional pain. In time, these energy blocks can cause illness.

Energy medicine aims to help the flow of energy and remove blocks in a similar way to acupuncture or acupressure. Improving the flow of energy around the body can enable relaxation, reduce pain, speed healing, and reduce other symptoms of illness.

What will happen in the Reiki session?

You will sit in a comfortable chair or lie on a table, fully clothed. There may or may not be music, depending on your preference.

The practitioner will place their hands lightly on or over specific areas of the head, limbs, and torso using different hand shapes, for between 2 and 5 minutes. The hands can be placed over 20 different areas of the body.

If there is a particular injury, such as a burn, the hands may be held just above the wound.

While the practitioner holds their hands lightly on or over the body, the transfer of energy takes place. During this time, the practitioner’s hands may be warm and tingling. Each hand position is held until the practitioner senses that the energy has stopped flowing.

When the practitioner feels that the heat, or energy, in their hands has abated, they will remove their hands and may place them over a different area of the body.

What are the benefits?

The healing effects are mediated by channeling the universal energy known as qi, pronounced “chi.” In India, this is known as “prana.” This is the same energy involved in tai chi exercise. It is the life force energy that surrounds all of us.

This energy permeates the body. While this energy is not measurable by modern scientific techniques, it can be felt by many who tune in to it.

Reiki can aid relaxation, assist in the body’s natural healing processes, and develop emotional, mental, and spiritual well-being.

It can also induce deep relaxation, help people cope with difficulties, relieve emotional stress, and improve overall well-being.

People who receive Reiki describe it as “intensely relaxing.”

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive the Reiki treatment.

Client Signature: *

Tap or click on the signature above to sign

Appointment Guidance

If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.

COVID-19 Symptoms:

a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
a loss or change to your sense of smell or taste
shortness of breath
feeling tired or exhausted
an aching body
a headache
a sore throat
a blocked or runny nose
loss of appetite
diarrhoea
feeling sick or being sick

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