Reiki Intake Forms

Reiki Session Intake & Waiver Forms

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Name *

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Address *

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Email *

Phone Number *

Birthday (Month) *

Birthday (Day) *

Occupation *

Emergency Contact *

Phone Number *

Relationship *

How did you hear about A Reiki Life Academy? *

Have you have a Reiki session before? *

Yes (In-person) Yes (Distance) Yes (Note in-person & Distance) No

Do you have any concerns or questions? *

Reiki Waiver:
For the purpose of this document, A Reiki Life, LLC and A Reiki Life Academy® are the same entity. I, the undersigned understand that the Reiki session or series of sessions received is for the purpose of stress reduction and relaxation. I understand very clearly that a Reiki session is not a substitute for medical or psychological diagnosis and treatment. Reiki practitioners do not diagnose conditions, nor do they prescribe, perform medical treatment, or interfere with the treatment of a licensed medical professional.

Reiki can be used as an aid for individuals in manifesting health and wellness for themselves. A Reiki Life Academy® makes no representations about the ability of Reiki to cure any illness or ameliorate any psychological conditions. Reiki may cause changes in the body called healing crisis that can make acute conditions feel worse in the first few days after a session.

I understand it is recommended that I see a licensed physician or licensed health care professional for any physical or psychological ailment that I have; and if I feel a change in any medication or treatment regimen may be necessary.

Waiver of Liability - I, the undersigned voluntarily agree to be the subject of a Reiki session or series of sessions from A Reiki Life Academy® and will indemnify and hold harmless A Reiki Life Academy® for any and all injury arising from my participation.

I, the undersigned understand the above, and have read, understand and agree to the Reiki session policies and voluntarily agree to engage in a Reiki session or ongoing Reiki sessions with Nancy Bunt.

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