Client Intake & Consent Form

All clients are required to fill out this form before services rendered.

PRIVACY NOTICE

No information about any client will be discussed or shared with any third party without the written consent of the client or parent/guardian if the client is under 18.

Name

First Name

Last Name

Date of Birth

YYYY

Gender

Female

Male

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Emergency Contact Name & Phone:

How did you hear about Sunflower SOL Portal?

Have you ever had a Reiki session before?

Yes

If yes, when was your last session, and how many previous sessions?

Do you have any particular area(s) of concern?

Are you sensitive to perfumes or fragrances or physical touch?

CLIENT'S CONSENT AND ACKNOWLEDGMENT

I understand that Reiki is a simple, gentle, hands-on energy technique used for stress reduction and relaxation. I understand and acknowledge 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 recognize that the body has the ability to heal itself, and complete relaxation is often beneficial for this process. I acknowledge that long-term imbalances in the body may require multiple sessions to facilitate the level of relaxation needed for the body to heal itself. By entering your full name below, you consent to this act as an electronic signature.