First Name*

Last Name*

Email*

Phone Number*

Date of Birth*

Session Type*

Please list any medical conditions, injuries, or health concerns

Current medications (if any)

Are you currently pregnant or trying to conceive?*

Do you have a pacemaker or other medical device?*

Have you consulted your GP/medical professional about receiving energy healing?*

What are your goals or intentions for this session?

I understand that Reiki and Crystal Healing are NOT a substitute for medical treatment and I should continue any prescribed medical care. please Type {i agree} in box below.*

For IN-PERSON sessions: I consent to light, non-invasive touch or hands hovering above my body during the session. please type{ i consent} i the box below.*

For REMOTE sessions: I consent to receive distance Reiki/Crystal healing energy at the scheduled time. please type{ i consent} in the box below*

I release the practitioner from any liability and understand results are not guaranteed. I have provided accurate health information. please type{ i consent}in the box below.*

Digital Signature (Type your full name)*

Date Signed*

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