Reiki Registration Form

Name:

Address:

Telephone Numbers:

Year of Birth:

Marital Status:

Children:

General Concerns:

Have you sought help for these before?  If yes, where?

EXPECTATIONS:

MEDICAL HISTORY:

STRESS RELATED/PSYCHOLOGICAL/EMOTIONAL HISTORY:

GPs NAME AND ADDRESS:

DETAILS OF CURRENT MEDICAL CONDITIONS:

OPERATIONS:

ACCIDENTS:

MEDICATION:

SERIOUS ILLNESS:

STRESS & STRESS-RELATED CONDITIONS:

I understand that Reiki is a complementary therapy and not a replacement for conventional medical or psychiatric treatment.  If I am already receiving conventional treatment, I shall inform other parties that I am receiving Reiki, if appropriate.  All information disclosed during treatment sessions shall remain confidential unless appropriate authorities will need to be notified by law.  The Practitioner reserves the right to refuse or postpone treatment if she feels physically unsafe, disrespected or abused.  I accept the fee payable and note that 24 hours notice is required for cancellation of an appointment, otherwise the full fee will be charged.

I understand that when I am receiving a distance healing that I should be prepared to follow the instructions given by my Practitioner for the duration of that healing session.

I have read the above and am willing to proceed with the treatment.

Signed                                                                            Date                                      Print Name

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