Client Intake and Waiver Form – Human Being Reiki Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Date of SubmissionName *FirstLastDate of Birth GEMMA overall provided. Address *Email *Phone No. *Gender *MaleFemaleDo not discloseReferred byThe session is intended for *MyselfMy Minor ChildIf the session is for a minor child please provide the following specific informationGender of Minor ChildMaleFemaleI prefer do not discloseName of Minor Child *FirstLastDate of Birth of Minor ChildPrimary Concern No.1Your main health issueLevel of Concern No.1 Selected Value: 11 (Hardly notice symptoms) to 10 (Symptoms are unbearable)Primary Concern No.2Your main health issueLevel of Concern No.2 Selected Value: 11 (Hardly notice symptoms) to 10 (Symptoms are unbearable)Primary Concern No.3Your main health issueLevel of Concern No.3 Selected Value: 11 (Hardly notice symptoms) to 10 (Symptoms are unbearable)Medications / Remedies / Supplements & Reasons for Taking *If nothing is taken, just type "NA"Significant Accidents / Injuries *If nothing happened, just type "NA"Please select any conditions that apply (past or present)CancerHeart diseaseDiabetesStrokeEpilepsyVaricose VeinsH/L blood pressureParalysisTMJ DisfunctionArthritisAllergiesSurgeryGenetic DisordersPhobiasPlease select any symptoms that you experienceHeadacheFaintness / DizzinessTightness in JawWeak Body PartSmokingNervousnessPoor AppetiteExcessive UrinationGrinding of TeethHeavy Feeling in LimbsBlurriness of VisionConstipationLoose Bowel MovementsIrritated BowelPain in Heart/ChestIndigestionInsomniaFatigueCold in Hands and FeetLower Back PainShoulder/Neck PainCarpel Tunnel SyndromeMenstrual IrregularitiesOther Non Listed SymptonsIf you select Other Symptoms, please specify here belowPlease specify Other Non Listed SymptomsPlease select any areas that you would like improvement inNegative Self-Talk / Self-SabotageBelieve in Ability to Achieve GoalsAbility to RelaxAbility to Use Dreams as Mental Tool for Problem SolvingEliminate ProcrastinationAbility to Reach Ideal WeightPersonal Magnetism StrengthenMemory / ConcentrationBreaking Old HabitsRelease Negative EventsAbility to Align Body/Mind for Self-HealingAbility to Take ActionIncrease Learning AbilityBeneficial RelationshipProsperity (attract what you choose)Attitude and Skills at WorkSelf-EsteemYouthful VitalityBelow, please describe what you would like to accomplish with these treatments *Additional Comment or MessageI consent to treatment for myself / my minor child, and understand that the services provided by the practitioner PAOLO GEMMA is intended to enhance relaxation and increase communication within my body. I understand that these services are not a substitute for medical treatment or medications. I am aware that diagnosis is not given and medication is not prescribed. I agree to continue to have regular medical check-ups as part of my overall health care plan. I understand that participation is voluntary and that at all times I may choose to end my participation. I understand that I may experience ‘healing reactions’ during the 24 to 48 hours following the services provided. I understand that any information exchanged during any session is educational in nature and is to be used at my own discretion. I also understand that any information imparted during these sessions is strictly confidential in nature and will not be shared with anyone without my written permission. I do, however, give the practitioner consent to use my case history and results without using my name. I understand that only the practitioner PAOLO GEMMA will have access to information in my file to enhance my healing. I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless both the practitioner PAOLO GEMMA and the facility/location where the services are provided. I agree to the terms and conditions set out by this consent form and certify that the above information is true and correct. I agree to pay for distance sessions, should I request them. *I do understand and authorizeSubmit
