Distance Reiki Consultation Form

Name*
Prefix First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current Medication & Dosage
Medication Dosage
Have you ever had a Reiki session before?*
- Yes
- No
When was your last session?*
Number of previous sessions*
What do you want from this Reiki treatment?
Are you happy for Head to Soul to share a video of your treatment on social media?*
- Yes
- No
Consent
Tick this box if you would not like to receive future workshops, promotions or communications
I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

I agree to my personal details and session notes being kept securely by Head to Soul Limited, up to a period of 7 years after treatment has ceased as per legal requirements.

I am happy to be contacted via phone, email or social media where necessary. I understand I can withdraw consent whenever I wish to.

I confirm I am over the age of 18 years old. / I confirm I am the legal guardian for the recipient who is under 18 years old.
Signature*
Date*
DD slash MM slash YYYY
Privacy Notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18.
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Medication	Dosage

Distance Reiki Consultation Form

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