Information + Liabilty Release

New Client Intake

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Emergency Contact Name + Relationship

Emergency Contact Phone

(###)

###

####

Are you currently under the care of a physician?

Yes

Current medications and dosage

Have you ever had a Reiki or Energy Session before?

Yes

If yes, when was your last session?

Number of previous sessions

Are you sensitive to perfumes or fragrances?

Yes

Are you sensitive to touch?

Yes

Payment Policy

All payments are paid in full and are non-refundable. All sessions expire after non-use, 30 days from payment.

Cancellation Policy

Appointments will be set for the same date and time every week. Appointments can be rescheduled only if in that same week. If you need to cancel an appointment please give me a 24 hour notice or you will be charged for the session. If there is a need for a non-emergency cancellation, you will be charged the full price of the session.

Reiki Energy Healing

In receiving Reiki from Sheri Bentley, I understand and acknowledge that Reiki is a simple, gentle energy healing technique that is provided both remotely and hands-on. It is most commonly used for stress reduction, relaxation and pain relief. Sheri Bentley does not diagnose conditions nor prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki can complement any medical or psychological care I may be receiving. I take full responsibility to see a licensed physician or a licensed healthcare professional for any physical or psychological ailment or condition as required, as I understand that Reiki does not take the place of medical care. I understand and agree that total relaxation contributes to my body’s ability to heal. I acknowledge that long term imbalances in the body sometimes requires multiple Reiki 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, I and any of my representatives agree to fully release and hold harmless Sheri Bentley from and against any and all claims or liability whatsoever, kind or nature arising out of or in connection with my session(s). Signature Release, By entering my name below, I fully agree and acknowledge these terms & conditions.

Life Coaching

I understand that the purpose of Life Coaching is to provide holistic + spiritual lifestyle instruction. I agree that, my Spiritual Life Coach will not be held liable in the event of any and all injury associated with activities that I participate in (i.e. any physical activity, spiritual guidance, emotional suggestions, mental help and/or instruction that I receive). I acknowledge that Sheri Bentley is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, psychotherapy, or any other type of medical advice. I acknowledge that coaching/training is another tool for teaching individuals about themselves, but that does not guarantee that coaching advice given by Sheri Bentley will produce good nor bad results. I acknowledge that Life Coaching may suggest exercise as part of my lifestyle and any risks of participating in these types of events/activities, will not hold Sheri Bentley liable. I waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind. I agree that this is the full agreement between the parties, that no one else has verbally contradicted any of the terms of this release and that I entered into this agreement free and voluntarily without force or coercion. Signature Release, By entering my name below, I fully agree and acknowledge these terms & conditions.

Date Signed

YYYY