Print name: ______________________________ Date: _________________________
Please read: I, the undersigned, understand that: Energy/Reiki/Crystal Therapy session is a hands-on (on respectful areas of a body) to enhance stress reduction, pain management, and/or relaxation technique; a Crystal Therapy session involves placement of crystals on my body to incorporate crystal energy into the session.
I understand very clearly that these sessions are not intended as a substitute for medical or psychological care.
I understand that Energy Practitioners do not diagnose conditions, nor do they prescribe medicines, nor interfere with the treatment of a licensed medical professional. It is recommended that I seek a licensed health care professional for any physical or psychological ailment I have.
The body has the ability to heal itself, and a complete relaxation is often beneficial. Long-term imbalances in the body sometimes require multiple treatments to allow the body to reach the level of relaxation necessary to bring the system back into balance. When individuals improve their self-improvement care, it benefits overall wellbeing.
I acknowledge my responsibility in my self-improvement process. I recognize that an ongoing self-care program must be followed to be truly effective, just as prescribed medication is only effective if taken as directed.
HEALTH INFORMATION:
Are you taking any other therapies? (i.e. chiro, massage, reflexology) ___________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Are you currently challenged from any of the following…
Y / S Inability to relax Y / S Feelings of insecurity Y / S Panic attacks
Y / S Lower back pain Y / S Spleen/Kidney/Gallbladder Y / S Lack of confidence
Y / S Digestive disorders Y / S Food/Eating habits Y / S Money
Y / S Emotional Confusion Y / S Lack of feeling boundaries Y / S Lack of self-care
Y/ S Speaking your mind too much/too little Y / S Able to self-express Y / S Listening skills
Y / S Headaches Y / S Do you trust your intuition? Y / S Dreams
Y / S Afraid of death Y / S Do you believe in a Higher Source?
Are you sensitive to essential oils / candle scents? Y / N
What are the most important challenges I can help you with today, and how severe are they?
Please list up to 3 concerns and rate the intensity, using a scale of 0 to 10
0 = barely noticeable and 10 = severe
|
|
|
|
|
|
|
|
|
|
Anything else you’d like to share? |
|
|
|
|
I consent to receive an Energy/Reiki/Crystal Therapy session from Dee Hughes, and have read the above noted information.
Preferred contact #: __________________________ Preferred email: _______________________
In case of emergency contact: ___________________________________
Emergency phone # for contact: ____________________________
Signed: ___________________________________ Date: __________________________________
