Form

Personalized Form for Your Wellness Journey

Discover a range of carefully designed forms to help us tailor your experience and guide you on your healing path. Whether you’re booking a consultation, sharing your wellness goals, or giving consent, these forms ensure personalized care that meets your unique needs. Together, we’ll create a nurturing space for growth, balance, and renewal.

Name

DOB

Occupation

Emergency Contact Number

Address

Phone Number

How Did You Hear About Valsu?

Do you have any current medical conditions or diagnoses? (If yes, please specify.)

Are you currently under the care of a medical professional?

Are you taking any medications, supplements, or treatments? (If yes, please specify.)

Do you have any physical injuries or conditions we should be aware of?

Have you experienced Reiki before?

What are your primary goals or intentions for this Reiki session?

Do you have any known sensitivities area to avoid?

Do you understand that Reiki is a complementary therapy and not a substitute for professional medical or psychological treatment?

Yes No

Do you consent to receive Reiki energy healing during this session?

Yes No

Do you give permission for your practitioner to lightly place hands on or near your body during the session?

Yes NO

Do you agree to inform the practitioner of any discomfort or concerns during the session?

Yes NO

Do you consent to your practitioner documenting session notes for professional use only?

Yes NO

Do you consent to being contacted for folow-up or feedback purposes?

Yes NO

Are you aware that Reiki results may vary and there are no guarantees for specific outcomes?

Yes No

Confirmation

I confirm that the information provided is accurate to the best of my knowledge

Acknowledgement

I acknowledge that I have read and understood the Reiki Consent Form and agree to proceed with the session.

Today's Date

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Limited-Time Offer

Take 10% off your first session and begin your healing journey today. Don’t wait—this special offer is available for a limited time only!