Reiki Client Information Form

Name

First NameLast Name

Date

MonthDayYear

E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Do you receive texts on this phone?

YesNo

Have you ever had a Reiki session before?

YesNo

Where did you hear about Kasey &/or Reiki?

Do you have any particular areas of concern (i.e. places of tightness or pain)?

Are you sensitive to fragrances?

YesNoSynthetic only (not essential oils)

Times of Sessions and Changes:

We will commit to begin and end our sessions on time. If you need to change or cancel your session please contact me at least 24 hours in advance. You will be charged for half of the session that is missed or cancelled without 24 hour notice (unless due to sickness or emergency). You may schedule an appointment online or by contacting me via email (khspiritualdirection@tds.net) or cell phone (615.598.5350).

Privacy Notice:

You have a right to expect confidentiality of the information we share with each other. Kasey commits to holding your conversations in the strictest confidence.

As part of her professional practice, she may consult her Reiki Master regarding your work together. This is intended solely to provide additional insight when necessary, however your identity will always be held in confidence.

She is permitted or required by law to disclose information without your consent or authorization in some situations. These situations are rare, such as the threat of harming oneself or others. If one arises, she will make every effort to discuss it with you before taking action.

I understand that Reiki is a simple, gentle, hands-on energy technique which can also be offered long-distance 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.

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