Client Consultation Form Client Consultation & ConsentPlease complete this confidential form before your first appointment.Step 1 of 41. Your detailsFull name *Email address *Telephone *Appointment date (if known)2. Your health and medical historyPlease let me know about any health conditions or concerns that may affect your comfort or needs during a Reiki session. Tick any that apply, whether current or previous. You can discuss anything privately with me before your appointment. Cancer Heart disease or heart condition Diabetes Stroke Epilepsy or seizures High or low blood pressure Varicose veins Paralysis or mobility impairment Arthritis TMJ / jaw problems Allergies Genetic or inherited condition Phobias or anxiety affecting the session Other relevant condition None of the aboveFurther details (where relevant)Medication, treatment and other considerations Taking prescribed medication Taking remedies or supplements Receiving ongoing medical treatment Previous significant accident or injury Recent or planned surgery Pregnant or possibly pregnant Accessibility, positioning or comfort needs None of the abovePlease provide any details you feel are relevant, including medication if applicable3. Current symptoms and wellbeingTick any symptoms you wish to tell me about. Headaches or dizziness Blurred vision Jaw tightness or teeth grinding Weakness or heaviness in limbs Cold hands or feet Back, shoulder or neck pain Chest pain or discomfort Digestive or bowel problems Poor appetite Frequent urination Difficulty sleeping or fatigue Nervousness or stress Menstrual irregularities Other symptoms None of the aboveFurther details (optional)Your goals for ReikiWhat would you like to gain from your session?4. Consent and understandingPlease read the following before agreeing:Reiki is a complementary wellbeing practice. I understand it is not a medical treatment, diagnosis or substitute for advice or care from a qualified healthcare professional. No particular result is promised.I understand I should continue any prescribed treatment or medication unless advised otherwise by my healthcare professional.I understand that Reiki is voluntary. I can ask questions, decline any part of the session or stop at any time. Kirsty will explain how the session is conducted, including her hands-off approach.I confirm that the information I have provided is accurate to the best of my knowledge and will tell Kirsty about any relevant changes before future sessions.I understand that my consultation information will be handled in accordance with the Reiki Doncaster privacy notice, including how my information is used, stored and retained and how I can exercise my rights.Privacy: Please read the privacy notice before submitting. The privacy notice must specifically explain how health information is processed. I explicitly consent to Reiki Doncaster processing the health information I provide for consultation and session records. I understand I may withdraw this consent by contacting Reiki Doncaster, subject to any other lawful retention requirements. I have read and understood the information above and agree to receive a Reiki session.Full name (electronic declaration) *Submission date and time are recorded automatically.BackContinueSubmit consultation
