Client Information and Release Form

Purpose and Overview

This form is intended to collect client information, obtain informed consent for Reiki and holistic healing services, and outline confidentiality, liability, and data protection measures. Reiki and Holistic healing sessions provided by Guillermina Neal | HealCoach are complementary practices designed to promote relaxation, stress reduction, and personal transformation. They are not a substitute for professional medical or psychological care.

1. Client Information

First name

Last name

Birthday

Address

Phone

Emergency Contact: Name, Phone Number, and Relationship:

2. Health Information

Are you currently under the care of a physician or other healthcare professional?

Yes

If yes, please provide details:

Do you have any chronic conditions, recent surgeries, or mental health concerns? (If yes, please specify).

Do you have any allergies, including to perfumes or fragrances? (If yes, please specify).

Are you sensitive to touch or have any areas of discomfort?

3. Experience and Goals

What are your primary reasons for seeking sessions (e.g., relaxation, stress reduction, specific health concerns)?

Do you have any specific areas of concern or goals for your sessions?

Have you ever received Reiki or other energy healing sessions before?

4. California Senate Bill SB-577 Disclosure and Acknowledgment

Under California Senate Bill SB-577, I am required to provide the following information:

1. I am not a licensed physician. Reiki and holistic healing services are alternative and complementary practices, and they are not licensed by the State of California.
2. Nature of Services: The services provided involve Reiki and holistic energy healing, which use hands-on or hands-off techniques to promote relaxation, reduce stress, and support overall well-being. These services are not intended to diagnose, treat, cure, or prevent any disease or medical condition.
3. Theoretical Basis of Services: The theory behind Reiki and holistic healing is that energy work can support the body’s natural ability to heal itself, and that achieving a state of relaxation may facilitate this process.
4. Consultation with a Licensed Provider: You are encouraged to consult with a licensed physician or other healthcare professional for any physical or mental health issues you may have.
5. No Diagnosis or Treatment: I do not diagnose or treat any medical or psychological conditions. If you have a severe health condition or are experiencing symptoms, you should consult a licensed healthcare provider.

Statement Required by California Law

The State of California has not adopted any educational or training standards for unlicensed complementary and alternative health care practitioners. This statement is provided pursuant to the requirements of California Business and Professions Code Section 2053.6.
Reiki and holistic healing are self-regulated and not licensed by the state. Services are designed to promote relaxation and personal growth. If you have a health condition, you are advised to consult a licensed healthcare professional.

By checking this box, I acknowledge that I have read and understand the above disclosures and that I voluntarily seek these services.

5. Informed Consent

By signing this form, I acknowledge and agree to the following:

Nature of Services

I understand that Reiki and holistic healing sessions are complementary practices that involve gentle, hands-on or hands-off energy techniques designed to promote relaxation and stress reduction.
These services are not a substitute for medical or psychological treatment, and the practitioner does not diagnose, treat medical conditions, or prescribe medications.
I have been advised to consult with a licensed healthcare professional for any medical or psychological conditions I may have.

Risks and Benefits

I understand that Reiki and holistic healing may produce various responses, including emotional release, temporary fatigue, or sensations of warmth or tingling.
Potential benefits include increased relaxation, improved stress management, and a sense of well-being. However, outcomes are not guaranteed.

Scope of Consent

I consent to receive Reiki and holistic healing sessions, understanding that I can withdraw my consent at any time.
I understand that my consent applies to a series of sessions unless explicitly revoked.

Assumption of Risk

I voluntarily assume all risks associated with receiving Reiki and holistic healing sessions. I release Guillermina Neal | HealCoach from any liability resulting from these sessions.

Indemnity Clause

I agree to indemnify and hold harmless the practitioner from any claims arising from the sessions, except in cases of gross negligence.

6. Confidentiality and Privacy

All information shared during sessions is confidential and will not be disclosed without my written consent, except as required by law (e.g., risk of harm to self or others, or cases of suspected abuse).
My personal data will be used solely for session-related purposes and communication, and will be stored securely in compliance with applicable data protection laws.

7. Communication Preferences

Would you like to subscribe to receive information about upcoming classes, meditations, articles, and healing resources?

Yes, subscribe me!

No, Thank You.

Preferred method of contact for appointment reminders and follow-ups:

Text

Phone Call

8. Cancellation and Refund Policy

1. Individual Sessions (e.g., Reiki, Coaching):

Cancellations within 24 Hours: Cancellations within 24 hours of a scheduled session will incur a $50 fee.
Rescheduling: I’m happy to work with you to reschedule a session, provided notice is given at least 24 hours before the appointment.
No-Show Policy: If you do not show up for an appointment without prior notice, the full session fee will be charged.

2. Session Packages (2 or 4 Sessions):

Package Duration: All sessions within a package must be scheduled and completed within 30 days of the first session.
Refund Policy for Packages: Refunds for unused sessions in a package are available only if cancellation is requested before the second session. Completed sessions will be billed at the single-session rate of $200, and the difference will be refunded.
Rescheduling Policy for Packages: Sessions within a package may be rescheduled, provided 24-hour notice is given.

3. Reiki Classes and Workshops:

Cancellation Policy: Cancellations for classes and workshops require at least 7 days' notice to receive a full refund. Cancellations made within 7 days of the event are non-refundable, but your payment may be applied toward future classes or workshops.
Transfers: If you cannot attend, you may transfer your registration to another participant by notifying me at least 24 hours before the event.

4. Class Series or Long-Term Commitments:

Refunds for Class Series: If you need to withdraw after the class series begins, a pro-rated refund is available only if notice is given before the second class.
Missed Classes: No refunds or credits for missed classes, but materials may be provided.

By checking this box I state that I have read, understand and agree to the cancellation and refund policy above.

9. Signature and Acknowledgment

By signing below, I confirm that I have read, understood, and agree to the terms outlined in this form. I acknowledge that I am seeking Reiki and Holistic Healing coaching or therapy voluntarily and that the information provided on this form is accurate to the best of my knowledge. I understand that Reiki is a complementary therapy and not a substitute for professional medical treatment. I agree to communicate openly with the Reiki Therapist and Holistic Healing Coach about any concerns or changes in my health before, during, and after each session.

Client Signature:

Date

For Minor Clients: Parent/Guardian Consent and Acknowledgment

I, the undersigned, confirm that I am the parent or legal guardian of the minor named in this form. I acknowledge that I am seeking Reiki and Holistic Healing coaching or therapy for the minor voluntarily and that the information provided on this form is accurate to the best of my knowledge. I understand that Reiki is a complementary therapy and not a substitute for professional medical treatment.

I agree to communicate openly with the Reiki Therapist and Holistic Healing Coach about any concerns or changes in the minor’s health before, during, and after each session. I acknowledge that I have read and understood all disclosures, policies, and terms outlined in this form, and I consent to the minor receiving Reiki and Holistic Healing sessions.

Parent/Guardian Name:

Parent/Guardian Signature (if client is a minor):

Minor’s Signature (if 12 years or older and able to understand the nature of the services):

Date

Thank you for choosing Guillermina Neal | HealCoach. Please feel free to discuss any questions or concerns you have with me before or during your session.