Intake Form | Sacred Hands Healing

Name *

Date of Birth *

Phone *

Email address *

Address *

City *

State *

Zip *

Have you had reiki healing before? *

Yes
No

Do you have difficulty lying on your back? *

Yes
No

Do you have any questions or concerns about receiving reiki or energy healing today? *

How do you feel - Physically? Emotionally? Mentally? Spiritually? *

Are you aware of recurring patterns in your life? *

What is uncomfortable in your life? *

Do you have emotional triggers? *

What are your personal healing intentions for your session today? *

Please let us know of any health concerns you’d like us to be aware of. *

Understand that the reiki and energy healing services I receive from Rodney Michaels are for the purpose of relaxation, stress reduction, and relief of tension. If I
experience any pain, discomfort, or distress during the sessions, I will immediately inform him so that the
techniques may be adjusted to my level of comfort or the session ended. I understand that reiki and energy healing
practitioners are not qualified to perform massage or spinal or skeletal adjustments, or diagnose, prescribe, or treat
any physical or mental illness, and that nothing said in the course of the session should be construed as such. I
understand that reiki or energy healing should not be construed as a substitute for medical examination, diagnosis,
or treatment, and that I should see a physician or other qualified medical specialist for physical or mental ailments.
Because reiki and energy healing should not be performed under certain medical and mental health conditions, I
affirm that I have stated all known conditions and answered all questions honestly. I agree to keep the practitioner
updated regarding any changes in my profile and I understand that there shall be no liability on the practitioner's
part should I fail to do so. It is my choice to receive reiki/energy healing. I am aware of the benefits and risks of reiki/energy healing and consent to receive it. I understand that there is no implied or stated guarantee of success or effectiveness of reiki/energy healing techniques. I understand that my health care records, communications, and transactions with the practitioner shall be kept confidential, unless I authorize the release of records in writing.
Clients under the age of 18 must be accompanied by a parent or guardian and informed written consent must be provided. All I ask is that you come with an open mind and willing to receive the greatest gift of devine love and powerful healing energy.

Signature *

Date *