Remote Reiki Consultation FormClient information and consent Name * First Name Last Name Date of birth * MM DD YYYY Contact number * Country (###) ### #### Email * Have you ever had a Reiki treatment before? * Yes No Do you have a particular area of concern? * Yes No How did you hear about us? * Social Media (eg. Instagram, Facebook) Search engine (eg. Google, Bing) Flyers Referral by friends/family CCDT (Chichester Community Development Trust) Terms of service * I understand that Reiki is a simple, gentle, hands-on session that is used for the purpose of stress reduction and relaxation, and to promote healing. I understand that a Reiki session is not a substitute for medical or psychological diagnosis or treatment. Reiki practitioners do not diagnose conditions nor do they prescribe, perform medical treatment, nor interfere with the treatment of a licensed medical professional. It is recommended that I see a incensed physician or licensed health professional for any physical or psychological ailment I have. Privacy notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18. Data Protection: We value your privacy and keep your information confidential. We won’t share your details with anyone outside of our service without your written permission. However, we may have to disclose information if a child is in danger or if a client poses a risk to themselves or others. In such cases, we will inform the appropriate authorities. Your data is kept securely for seven years. You can ask for a copy of our data protection policy at any time. Data protection laws allow you to request your notes and have them removed. I have read and understand this, and I ask for Reiki Therapy. I know my practitioner is not responsible for the session outcomes. I consent to use the services of Evelina Campbell from The Cosmic Zen and will pay for them. Client Acknowledgment: I recognise that a Reiki Therapy Practitioner does not diagnose or treat medical conditions and does not interfere with licensed medical professionals. I understand these therapies are not substitutes for medical care. I will inform Evelina Campbell of any relevant changes to my condition, like pregnancy or epilepsy. I am aware that it is my duty to submit truthful information. I agree to the terms of service Thank you for submitting the form!
