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Transitioning to End-of-Life Services
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Gonda LLC
Energy Healing Intake Form
Please take a moment to fill out the form.
All information is kept confidential.
Choose your session:
*
Required
Runes & Reiki Healing
Chakra Tune-Up
In-person Reiki Session
First Name
Last Name
Email
Phone number
Select Pronouns
*
She/Her/Hers
He/Him/His
They/Them/Theirs
Select an Address
Emergency Contact Information
Emergency Contact Phone
Please List Any Allergies or relevant Medical information
Have you ever had reiki or any form of energy healing before?
Energy Healing can be hands on or hands off. Are you comfortable with light touch?
*
Hands On
Hands Off
Do I have permission to smudge with sage or palo santo
*
Yes
No
Do I have permission to use crystals?
*
Yes
No
Do I have permission to use sound therapy? This could include headphones, tuning forks, drums...etc
*
Yes
No
Do I have permission to use red light therapy?
*
Yes
No
Do you have an intention for your session?
Are there areas of your body you would prefer the healing to be focused, or areas to avoid?
TREATMENT CONSENT FORM: I understand that Reiki and Energy Healers do not diagnose illness, disease, or mental disorder. Nor do they prescribe medical treatment or pharmaceuticals. It has been made clear that any energy healing is not a substitute for medical examination or diagnosis and that it is recommended that I see a MD/ND for any physical or mental ailment. With this in mind I agree that Reiki and Energy Healers (Gonda LLC) cannot be held liable for any problems that might arise that I think could be attributed to the energy healing season. I have stated all of my known medical conditions to my provider and if necessary, I will keep them updated on my physical, mental, and emotional health. I acknowledge that the Reiki/Energy Healing by Gonda LLC practice for the purpose of providing mental/emotional/physical and spiritual support using intuitive energy healing techniques. I attest that I understand the nature of the treatment and freely elect to receive treatments. I release the providers from any and all claims of malpractice, non-disclosure, or lack of informed consent.
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