Tranquility Massage Therapy & Reiki LLC

Transcription

1 CLIENT INFORMATION NAME: ADDRESS: PHONE NUMBER: HEALTH INFORMATION HAVE YOU BEEN DIAGNOSED WITH A PHYSICAL DISEASE? Y N IF YES, GIVE DETAILS: HAVE YOU BEEN DIAGNOSED WITH A MENTAL DISORDER: Y N IF YES, GIVE DETAILS: DO YOU TAKE PRESCRIPTION DRUGS? Y N IF YES, PLEASE LIST HAVE YOU EVER SUFFERED FROM OR BEEN DIAGNOSED WITH EPILEPSY OR SEIZURES? Y N CURRENT CONDITION FOR WHICH ALTERNATIVE TREATMENT IS SOUGHT: If you could make immediate changes to your life and the way you experience things or act, what would they be:

2 What do you see as your perfect future self after these changes have taken place? Please circle the emotions that you are currently experiencing: Dignity/ Respect/Self-Worth Freedom/Control Love/Connection/ Importance Justice/Truth Safety Trust Ashamed Beaten down Cut down Criticized Dehumanized Disrespected Embarrassed Humiliated Inferior Insulted Invalidated Labeled Lectured to Mocked Offended Put down Resentful Ridiculed Stereotyped Teased Underestimated Worthless Bossed around Controlled Imposed upon Imprisoned Inhibited Invaded Forced Manipulated Obligated Over-controlled Over-ruled Powerless Pressured Restricted Suffocated Trapped Abandoned Alone Brushed off Confused Disapproved of Discouraged Ignored Insignificant Invisible Left out Lonely Misunderstood Neglected Rejected Uncared about Unheard Unknown Unimportant Uninformed Unloved Unsupported Unwanted Accused Blamed Cheated Disbelieved Falsely accused Guilt-tripped Interrogated Judged Lied about Lied to Misled Punished Robbed Abused Afraid Attacked Defensive Frightened Insecure Intimidated Over-protected Scared Terrified Threatened Under-protected Unsafe Violated Cynical Guarded Skeptical Suspicious Untrusted Untrusting Disclaimer: I, the recipient and client as stated above, understand that Energy & Spiritual Healing is not meant to replace conventional medicine but rather to complement it. If symptoms persist, a medical profession is to be consulted immediately. I hereby release the person(s) providing Energy & Spiritual Healing & the Tranquility Massage Therapy & Reiki LLC from any liability as a result of the services received by me. I understand that at no point should I stop taking prescribed medication or change the dosage without my primary care physician s recommendation or approval. I also declare that I have medical clearance from my medical doctors, to seek Energy & Spiritual Healing as a complimentary form of alternative treatment to my conventional medical treatment. PRINT NAME: SIGNATURE: DATE:

3 Reiki Informed Consent Form This record of consent is required before the first assessment or treatment and will be maintained confidentially in the client file. It may only be released to a third party with prior written consent of the client. By signing below, the client agrees to the following: All Reiki treatments, information and records will be kept confidential and securely stored for use only by the massage therapist. Written consent must be given by me prior to any disclosure or sharing of my personal and clinical information with any third party. I freely give my permission to receive Reiki treatments. I agree to inform the therapist of any experience of pain during initial and subsequent sessions. I agree to update the therapist on changes in my health status and understand that no liability on the therapist s part shall exist if I should neglect to do so. I understand that Reiki does not replace or substitute medical examination/care and the therapist does not diagnose; I should see a medical physician, chiropractor or other health care provider to address concerns that are outside the scope of massage therapist s practice. I understand that promptness is expected for all appointments. In the event of lateness, I understand the following: o the session may be cut short due to other commitments of the therapist; o the therapist may cancel/reschedule the massage appointment due to other commitments; o fees will be maintained per the schedule and are due prior to departure on the day of treatment. Cancellation of any appointment must be received at least 24 hours in advance; otherwise the full appointment fee is due. I understand that the therapist may refuse to treat a client that makes her feel unsafe or a client who makes sexual advances. I, (PRINT NAME), have read and understood the information above and consent to massage treatment for the conditions discussed with my therapist today. Client signature: Date:

4 Financial Policy Initial Intake and Treatment $80 for 60 minute Reiki session Follow up appointments $80 for 60 minute Reiki session Cash, checks and credit cards are accepted and due at the time of treatment. Cancellation Policy: All scheduled appointments require a 24 hour cancellation notice or the patient will be charged for the FULL office fee. My contact information: Claire Metzler Phone: Website: clairemetzler@massagetherapy.com Patient Signature: Print Name: Date:

5 Office Policies Client Information Client Name: Date: Date of Birth: Please be advised of the policies for this office. Your signature below signifies acceptance of these policies. Cancellation A 24-hour notice is required for cancellation of an appointment, or you will be charged in full for the appointment. Payment is due before your next appointment. Tardiness Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please be on time to your appointment. Sickness Massage/bodywork/MLD/Reiki is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived. No call/no show Policy Current credit card information is required to be on file with this office. Your credit card will only be charged for no call (see above regarding cancellations) and no show appointments. Inappropriate Behavior Policy Massage therapy/mld/reiki is for relaxation and therapeutic purposes only. There is absolutely no sexual component to massage/mld/reiki whatsoever. Any insinuation, joke, gesture, conversation or request will result in an immediate termination of the session and refusal of any and all services in the future. You will be charged the full session fee regardless of the length of your session. A report will be filed with the local and/or state authorities. Treat your therapist with respect and dignity and you will be treated the same in return. I, (PRINT NAME), have read and understood the information above. Client signature: Date: