Reiki Intake Form — Rise to Thrive: Reiki and Parent Coaching

Name

First Name

Last Name

Email

Phone

(###)

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Emergency Contact Phone

(###)

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Current medications and dosage

Physicians name, if under care of

Describe any particular area of concern

How did you hear about us?

Have you ever had Reiki before? How many sessions, and when last?

Describe any perfume or fragrance sensitivities

Describe any touch sensitivities

Check to Acknowledge

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand 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 aliment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.

Acknowledge

Decline

Please Type to Sign

Type as: Your Name - Today's Date (MM/DD/YYYY)

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

DISCLAIMER: I am a nurse practitioner (NP) and I work at the #1 pediatric primary care practice in the Charleston area. I have extensive training and experience in providing health care services to children and families. As a reiki practitioner and parent coach, I can use some of my skills and knowledge to help you with your personal & parenting challenges and goals. However, please note:

Reiki and/or parent coaching is not a substitute for medical advice or treatment. If you or your child have any health concerns or need medical attention, please consult your primary care provider or seek emergency care.
Reiki and/or parent coaching is not covered by insurance. You will be responsible for paying the fees for the coaching sessions and any related expenses.
Reiki and/or parent coaching is not regulated by the state board of nursing or any other licensing authority. My NP license does not authorize me to provide parent coaching services outside of my scope of practice as a health care provider.
Reiki and/or parent coaching is based on a collaborative and voluntary relationship between you and me. You are free to terminate the coaching sessions at any time. You are also responsible for your own actions and decisions as a parent.
I cannot perform services that are in competition with my current employment agreement.

By acknowledging above and submitting this form, you have read and understood the above information and that you agree to the terms and conditions of reiki & parent coaching with me.

Let’s work together

Sarah Conrad, MSN, CPNP, Reiki Master, Mother