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Reiki Intake Form

New Client

Please fill this form out before your first Reiki Session with Kim.

How did you hear about us?
Have you received Reiki before?

Reiki Disclaimer 

I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long-term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself.


Except in the case of gross negligence or malpractice, my representative(s) or I agree to fully release and hold harmless, Kim Couillard, from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).”

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