Hannah’s Healing Reiki Client Information Sheet PO Box 333 Leeds, NY !"# Reiki $aster %&ril Hannah
Name: __________________________ ______________________________________ _________________________ _________________DOB:_______ ____DOB:__________ ___ Age:_____ Address:____________________ Address:________________________________ _________________________ __________________________ __________________________ __________________ _____ _________________________ _____________________________________ _________________________ __________________________ __________________________ ______________________ _________ __ Phone/Cell: _________________________ _____________________________________ _____________Email:____________ _Email:_________________________ __________________________ _______________ __ __ Profession:___________________ Profession:________________________________ __________________________ __________________________ __________________________ _______________ __ ___ Emergency Contact - Name/Number: elationshi!:_____________________ elationshi!:_________ _________________________ __________________________ __________________________ ________________ ___ Name: __________________________ ______________________________________ _____________"____________ _"________________________ ________________ ____ #ould you li$e to be added to our email -list for u!dates about u!coming classes and e%ents& Please chec$ one: ' ( )es ' ( No *han$s ' ( Already on the list+ ' ( , dont use email .o did you hear about .annah0s .ealing& ' ( 1a an add or listing in_____________________ in_____________________ ' ( 2ound it on the eb ' ( eferred by _____________________________ _____________________________ ' ( 1a a 3yer or got a business card at ' (Other______________________ (Other___________________________________ __________________________ _________________________ _________________________ _____________ Session Consent Statement' ,4 the undersigned4 understand that the ei$i session gi%en is for the !ur!ose of stress reduction and rela5ation6 , understand %ery clearly that a ei$i session is not a substitute for medical or !sychological diagnosis or treatment6 ei$i !ractitioners do not diagnose conditions4 !rescribe or !erform medical treatment4 or interfere ith the treatment of a licensed medical !rofessional6 ,t is recommended that , see a licensed !hysician4 or licensed health care !rofessional for any !hysical or !sychological ailment , ha%e6 , also understand that ei$i is a form of non-in%asi%e and non-mani!ulati%e touch6 ,f , am uncomfortable in any ay during my session , ha%e the right to 7uestion my !ractitioner and/or re7uest that the session be terminated6 ,f , e5!erience any !ain or discomfort during the session4 , ill immediately inform my !ractitioner so that the !ressure and/or touch may be ad8usted to my le%el of comfort6 Any illicit or se5ually suggesti%e remar$s or
ad%ances made by me ill result in immediate termination of the session4 and , ill be liable for !ayment of the scheduled a!!ointment6 , understand that comfortable clothing is re7uired to ear at all times during my ei$i session6 , a9irm that , ha%e stated all $non medical conditions and ansered all 7uestions honestly6 , agree to $ee! the !ractitioner u!dated as to any changes in my medical !role and understand that there shall be no liability on the !ractitioners !art should , fail to do so6 Client 1ignature:_________________________________________Date:_____________________ Practitioner 1ignature:_____________________________________Date:____________________ Practitioner Name4 Please Print:_______________________________________________________ Consent to Treatment of Minor:
By my signature belo4 , hereby authori;e A!ril
.annah4 ei$i
ineage to administer ei$i to my child or de!endent as they deem necessary6 Parent/?uardian 1ignature: _____________________________________________________________________ Health ()estionnaire' @6 .a%e you e%er had a ei$i session before& ' ( yes ' ( no ,f yes4 for hat !ur!ose&
'general ellness4 stress reduction4 etc( _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 6 #hat do you ho!e to accom!lish ith this ei$i session& ' ( ela5ation ' ( 1tress eduction ' ( Pain eduction ' ( Other '!lease e5!lain( __________________________________________________________________________________ __________________________________________________________________________________ 6 Do you ta$e any medication on a regular basis& ' ( yes ' ( no Please list medications and the conditions theyre addressing __________________________________________________________________________________
__________________________________________________________________________________ 6 Are you !regnant& ' ( yes ' ( no 6 Chec$ ith an 5 if you ha%e any of these conditions: ' ( Arthritis ' ( Asthma ' ( Bac$ Pain4 ________________________________ ' ( Bleeding ' ( Circulatory Problems ' ( Diabetes ' ( E!ile!sy or 1ei;ures ' ( 2re7uent .eadaches ' ( .eart Ailment ' ( oint 1elling ' ( 1$in Disorders/rashes___________________________ ' ( *< 1yndrome ' ( >o or ' ( .igh Blood Pressure ' ( Allergies/ 1inus 4 Please e5!lain: ____________________________________________________________________ ' ( ,nfectious Condition4 Please >ist:____________________________________________________________________ ' ( Physical Pain 4 Please e5!lain: ______________________________________________________________________ ' ( *ension or 1oreness in a s!ecic area4 Please >ist: _______________________________________________________ ' ( ecent ,n8ury or 1urgery 4 Please >ist: ________________________________________________________________ F6 Are you sensiti%e or uncomfortable ith a ny touch or !ressure in any area& ____________________________________ G6 Are you sensiti%e to fragrances or !erfumes& ___ yes ___ no H6 Please s!ecify any other conditions4 !hysical4 mental4 emotional or otherise hich you feel may be im!ortant: ______________________________________________________________________________
