Reiki Form | Ripples Wellbeing

First name

Last name

Gender/Preferred pronoun

Date of birth

Address

Phone

Do you work with any other agencies?

(e.g. social worker, mental Health support, other support/counselling services)

Your GP (name and surgery)

Name and telephone number of next of kin (that we can contact in case of emergency)

Do you have any medical conditions or health concerns? Please also list any medication you are taking

Please set out any accessibility requirements you may have

Previous experience of reiki, if relevant

What is the main reason for seeking reiki healing?

Please let us know your availability (the more flexible you can be, the earlier we may be able to book you in)

Fees/Payment

Your first session with Heidi will include a consultation in addition to a 45-minute Reiki treatment at a cost of £50.00.

Subsequent sessions are charged at £45.00 for a 45-minute treatment and £35.00 for a 30-minute treatment.

A block booking option is also available:

• Four x 45-minute sessions for £150.00 (a total reduction of £30.00),

• Four x 30-minute sessions for £120.00 (a total reduction of £20.00)

We reserve the right to not continue if payment has not been made in advance of your session.

If you are within the low-income category, please contact us to discuss what options are available.

Signing this form means you agree to the following:

I agree to this referral and to sharing this information with Ripples Wellbeing and the Therapist
I understand that reiki is not a substitute for qualified medical advice and/or treatment.
I understand that there is no guarantee in relation to the outcome of reiki treatment.
I agree to information sharing with partner agencies when necessary.
I agree to secure storage of my personal details.

Signature

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