Session Form
Wildflower Wellness Center
Consent Form
Hypnotherapy, Reiki, & Coaching
Personal Information
Name:
Date:
Birthday:
Address:
City:
State:
Postcode:
Phone:
Email:
Occupation:
Emergency Contact Name:
Relationship to you:
Emergency Contact Phone:
How did you hear about us?
Medical Information
Do you have any diagnoses you wish to share?
Do you have any current medications you wish to share?
Do you suffer from chronic pain? Yes No
If yes, please advise:
Is there anything that makes it feel better or worse?
Have you had any injuries? Yes No
If yes, please advise:
Session Information
Have you ever had Hypnotherapy, Reiki, or Coaching session before? Yes No
If yes, how long ago, and what was the outcome?
Have you ever had any other holistic or natural healing performed before? Yes No
If yes, what was it, and how long ago and what was the outcome?
What are your goals (physical, emotional, and/or spiritual) for this session?
What is your intention for this session?
Client Acknowledgments
Reiki Education and Training: I was trained in Reiki (Level 1-4) through three separate teachers at different levels of certification, and each certification is recognized by the International Association of Reiki Professionals.
Reiki Notice: The state of Indiana has not adopted any educational and training standards for the practice of Reiki. This statement of credentials is for information purposes only. Reiki is a self-regulating profession, and its practitioners are not licensed by state governments. I am neither a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to coordinate the transfer of services to another practitioner. A client has a right to refuse reiki services at any time. A client has a right to be free of physical, verbal, or sexual abuse. A client has a right to know the expected duration of sessions and may assert any right without retaliation.
Reiki Redress: I practice in accordance with the Code of Ethics and Standards of the International Association of Reiki. If you ever have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the International Association of Reiki at Reiki | International association of REIKI professionals IARP (iarpreiki.org) to seek redress. Other services than my own may be available to you in the community.
Reiki Fees: The charge for Reiki is $111.00 - $133.00 per session
Hypnotherapy.Education and Training: I was trained in hypnotherapy at iNlP Center, an International Hypnosis Federation accredited program. I am a Certified Member of the International Hypnosis Federation, and I do annual continuing education to maintain my training at a high level.
Hypnotherapy Notice: The state of Indiana has not adopted any educational and training standards for the practice of hypnotism. This statement of credentials is for information purposes only. Hypnotism is a self-regulating profession, and its practitioners are not licensed by state governments. I am neither a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to coordinate the transfer of services to another practitioner. A client has a right to refuse hypnotism services at any time. A client has a right to be free of physical, verbal, or sexual abuse. A client has a right to know the expected duration of sessions and may assert any right without retaliation.
Hypnotherapy Redress: I practice in accordance with the Code of Ethics and Standards of the International Hypnosis Federation. If you ever have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the International Hypnosis Federation at (310) 541-4844 to seek redress. Other services than my own may be available to you in the community.
Hypnotherapy Fees: The charge for Hypnotherapy is $140.00 - $180.00 per session. In combination with Reiki, this session ranges from $160.00 - $222.00.
Life Coaching Education and Training: I have a Professional Life Coach certification, accredited through the International Coach Federation. I completed this certification through the Life Coach Institute.
Life Coaching Notice: The state of Indiana has not adopted any educational and training standards for the practice of coaching. This statement of credentials is for information purposes only. Coaching is a self-regulating profession, and its practitioners are not licensed by state governments. I am neither a physician nor a licensed health care provider and may not provide a medical diagnosis nor recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event my services are terminated by a client, the client has a right to coordinate the transfer of services to another practitioner. A client has a right to refuse coaching services at any time. A client has a right to be free of physical, verbal, or sexual abuse. A client has a right to know the expected duration of sessions and may assert any right without retaliation.
Life Coaching Redress: I practice in accordance with the Code of Ethics and Standards of the International Coach Federation. If you ever have a complaint about my services or behavior that I cannot resolve for you personally, you may contact the International Coach Federation (www.coachfederation.org/ethics) to seek redress. Other services than my own may be available to you in the community.
Life Coaching Fees: The charge for a Coaching session is $90.00 per session. This fee is non-refundable, but if twenty-four-hour notice is given, a credit for the next available session can be used.
Confidentiality: I will not release any information to anyone without written authorization from you, except as provided for by law. You have a right to be allowed access to my written record about you.
Insurance: I suggest you think of my services as something you will pay for personally. That will both protect your privacy and help you value the work you are doing more. In general, insurance companies do not generally cover Reiki, Hypnotherapy, or Life Coaching services, and I caution you not to expect them to do so.
Client Signature::
By signing the below, I agree I have completed this form as honestly and completely as possible, and will advise if anything changes at any time. I have received and read this Consent Form and Wildflower Wellness Center’s Disclaimer Form (located on website - www.wildflowertales.org) and understand what I have read.
Client’s Name: Signature: ____________________________
Date: __________________________
Responsible Party Name (If under the age of 18): Responsible Party Signature: ________________________________
Date: ___________________________