Patient information

Name: ______Date:______

Address: ______

Home Phone: ______Work Phone: ______Cell Phone: ______

Email: ______

1. How did you hear about my services? ______

2. Have you had any Energy based treatments before? Yes/No If yes, date of last session: ______

3. Do you have any additional comments or questions before we begin your session? ______

______

Explanation and Consent Form

What is Reiki and Bio-Energy?

Reiki and Bio-Energy are forms of omnipresent universal energy that can be used to facilitate healing and wellness. Patient experiences may vary for each patient and for each treatment.

What to expect during a session

Some patients report a feeling of a glowing warmth, or a slight to mild tingling sensation, others a report a sense of overwhelming calm or bliss. Patients can experience anyone or all of the above. The more open an individual the more intense the sensations tend to be

The history and acceptance of Healing Energies

The use of energy healing has been around for many thousands of years and has been documented in virtually all the major societies and cultures from the beginning of recorded time.

Throughout the world the use of healing energy has been found to be safe and free of any side effects. The use of healing energies such as Reiki and Bio-Energy is currently being used in many of the world’s traditional medical establishments. The use of these practices has gain mass acceptance in the western world and is no longer considered far eastern or old world practices. Today such treatments are common place in western society to the extent that now many of the worlds’ leading cancer centers provide REIKI after and during the traditional regime of surgery, radiation, and chemotherapy. These centers have documented the positives results of using energy medicines to complement traditional medicine.


Energy Work is NOT a replacement for medical treatment!

Patient Consent:

As someone who works with energy healing my services neither diagnoses nor prescribes medical conditions. All clients are encouraged to seek competent medical help when those services are deemed necessary. The client accepts total responsibility for his/her own health care and maintenance. Nothing said, typed, printed, or produced by me is intended or meant to diagnose, prescribe, treat a disease, or take the place of a licensed physician.

I ______certify that the services offered by The Circle of Truths do not interfere or conflict with any treatment I may be taking under the guidance of a licensed medical professional, if any doubt or conflict I will discontinue the services of the Circle of Truths. I also understand that it is not massage therapy, or physiotherapy or any other forms of regulated therapies. It is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment I have. By signing below, I acknowledge and fully agree with the above information.

Signature of Client: ______

Dated of session: ______

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