Energy Healing Registration, Intake & Consent Form

This form is used to learn more about your journey towards healing. This is also used to ensure your consent to proceed with Energy Work

Date of Appointment *

First Name *

Last Name *

Date of birth *

Phone *

Street Address *

City

State

Country

Postal code

Email *

Women Only: Are you Pregnant? *

Yes

Due Date

Please list any special health issues or requirements I need to know about (include health restrictions, allergies or other serious health concerns, and if required information on emergency care and your doctor): *

Have you had an Energy Healing session before? *

Yes

If you have had an Energy Healing Session before, how would you describe your experience *

Is there a specific reason why you are here today? *

What do you hope to gain from your Energy Healing experience? *

Other Reason(s) Why I am here ( please explain) *

Are you currently seeing a medical professional, holistic practitioner and/or Energy Worker? *

What else are you doing to supplement your physical, mental and emotional health? *

Are you interested in learning more about Energy Healing? *

Yes

Not sure

Are you interested in any of our other energy healing sessions and/or workshops? *

Yes

Not at this time, maybe sometime in the future

Do you understand and agree that every Energy Healing Practioner can vary in their methods and process in their session? *

yes

Do you understand that while you might be here for a specific reason, an alternative or additional topic/issue/question/concern may arise that you may or may not have expected? *

Yes

Energy Healing is a hands-on and hands-off holistic health treatment to encourage relaxation and healing. Energy Healing is practiced while the client is fully clothed, on a massage table. If at any time you feel discomfort, you may ask for the session to be stopped immediately (session can be resumed at the comfort level of the client). Sessions are most effective in silence, but sometimes it is necessary to voice what you are feeling, particularly for those unfamiliar with Energy Healing, in order to feel at ease. Please note, for serious health conditions please see a licensed medical practitioner. For such conditions Energy Healing is considered a complementary form of treatment. *

I UNDERSTAND AND AGREE

I understand the above statement in regards to services offered and give permission for TASGM to perform such services as outlined above, and state that I have disclosed any information (health or otherwise) that may alter the effectiveness of services offered. * I understand that if at any time I feel discomfort or have a problem with the session, it is my responsibility to voice my concerns. * I understand that TASGM an independent practitioner and separate from any healthcare provider. * I understand that payment is required prior and at time of services offered; I must give 24-48 hours notice for cancellations to avoid cancellation fees; and at any time during a session I can request to stop session, though this may not entitle me to a refund. * I understand that workshops and classes are non-refundable but are transferable, however special circumstances will be considered. *

I UNDERSTAND AND AGREE

Please note that my Energy Healing practice is generally a hands-on healing practice. While there is a protocol of hand positions, I also work intuitively as to where to place my hands and which hands positions to use. My hands will rest lightly on your body and there is no manipulation of your body. If, at any time, you are uncomfortable, I can switch positions, or use the floating hands method. There is no difference in the benefit experienced by the placement of my hands on your body versus floating my hands over your body. Should you desire to alternate positions during the treatment, please feel free to ask me to do so. *

I UNDERSTAND AND AGREE

Before your session, please read over each section, then check off the 'I AGREE AND UNDERSTAND' at the bottom to continue *What is Reiki? The Usui System of Reiki Healing is a palms-on healing practice. Reiki is an ancient laying- on-of-palms healing technique that uses the Universal life force energy to balance the subtle energies within our bodies and to heal. Reiki practitioners act as a conduit or channel through which Reiki energy travels. The intended result of receiving Reiki is a balanced physical, mental, emotional, and spiritual being. Reiki is being used today in clinics and hospitals all over the world to support health, wellness and transition. *What happens during a Energy Healing treatment? During a Energy Healing treatment, you will lay fully clothed on a massage table, covered in a blanket if you choose, listening to soothing music. Your Energy Healing practitioner will lay their hands on your body in a series of hand positions to deliver Energy Healing. Most Energy Healing treatment generally covers first your head then the front of your body and possibly the back of your body. If the reclined position is uncomfortable, Energy Healing can be performed while you sit in a chair or on a stool. Please let your Energy Healer know ahead of time so he/she can prepare the room to your comfort. * What does Energy Healing feel like? Energy Healing tends to feel warm and profoundly relaxing. You may feel the hands of the Energy Healing practitioner become hot or tingly. Some people describe a floating sensation and some see colors or shapes during the session. Some people fall asleep. Some experience emotional release. There is no expected experience. Go into the Energy Healing with no expectation and come out with your own experience. Energy Healing treatment is unique for each individual who receives it. *The most common results of Energy Healing treatment include: *Perceived reduction in stress *Increased relaxation *Enhanced sense of balance, centeredness and calm *May increase in confidence* May increase awareness *May increase or decrease energy level in order to help body balance *May experience crying as a release of emotion. * May experience sleepiness after session and a sudden burst of energy*Each experience varies * What are the benefits of several sessions? Just like meditation, or movement arts, the effects of Energy Healing are cumulative. While one session can work wonders, repeated, regular Energy Healing treatments can invite significant improvement. As an example: if you exercise for an hour, you will receive benefit. If you exercise every day for a month, the results will be much more profound. Energy Healing works similarly – regular sessions support well-being in every way. *Can Energy Healing “cure” me? Energy Healing is a complementary medical art that works well alone as well as in concert with other treatments. Healing is often the result of gentle shifts in awareness, release of emotional patterns, achievement of new understanding, and daily practice. Energy Healing is not a replacement for traditional medical treatment. I understand that Energy Healing is a relaxation and stress reduction technique. I acknowledge that treatments administered are only for the purpose of helping me relax and to relieve stress. Energy Healing practitioners do not diagnose conditions, nor do they prescribe substances or perform medical treatment, nor interfere with the treatment of a licensed medical professional. I further understand that Energy Healing treatment received from practitioners at TASGM are not to be construed as a substitute for medical examination, diagnosis or treatment. It is recommended that I see a licensed health care professional for any physical or psychological ailment I may have. I also understand that Energy Healing is an energetic healing methodology, which involves the laying on of hands. I understand that I will be fully clothed during the session, and experience a series of hand positions on and/or above my body. Having read, completed and understood the foregoing, I request to receive Energy Healing treatment. I understand that my practitioner is providing Energy Healing treatment for me at my request, and is not responsible for the outcome of the Energy Healing session. I agree to hold TASGM harmless for any intended or unintended result. 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. *

I UNDERSTAND AND AGREE

IMPORTANT: Please read each statement carefully and sign below indicating that you understand and accept the following: I give consent to receive a healing session and agree to pay the fee upon completion of this service. As a courtesy to the healer I will cancel my appointment at least 24 hours in advance, if needed. I understand there is a $35 fee for not showing up for my appointment and may not get reimbursed for workshop or session fee. True emergencies will be handled accordingly between client and healer. I agree to pay the full fee for my scheduled appointment if I am late and understand I may not receive a full-length session. I also understand that any illicit or sexually suggestive remarks or advances made by the client will result in immediate termination of the session, and the client will be liable for payment of the scheduled appointment. NOTE: TASGM reserves the right to deny service. *

I have reviewed and agree to all the above terms

Comments, Suggestions, Inquiries?

By typing your name below, you accept or authorize this document like you have physically signed it. Your digital signature below indicates that you have read and completed the form. *

Please provide a digital signature *

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Step 1: Complete the Registration Form

“If you could learn in a way that also helps you heal, would you?”

— anonymous