Client Intake & Consent Form

About You

Full Legal Name Preferred Name Date of Birth Email Address Phone Number Emergency Contact Name Emergency Contact Phone Number Relationship to You

Your Session

Which experience are you attending?

Private Reiki Session Private Reiki + Sound Session Group Sound Bath Other

Is this your first experience with Reiki?

Yes No

Is this your first experience with sound healing or a sound bath?

Yes No

What has brought you to your session today? Select any that apply.

Relaxation Stress reduction Feeling overwhelmed Grounding Rest Meditation / mindfulness Emotional wellbeing Spiritual or energetic exploration General wellness / self-care Curiosity

Is there anything you would particularly like support with during your session?

Health & Safety

Sound and vibration can be experienced physically as well as audibly. Certain instruments may be played near the body and, during private sessions and with your permission, may sometimes be placed on the body. Please answer the following so I can determine whether modifications may be appropriate.

Do any of the following currently apply to you? Select any that apply.

I am pregnant or think I may be pregnant I have a pacemaker or other implanted electronic medical device I have epilepsy or a history of seizures I experience tinnitus or significant sound sensitivity I have hearing loss or use hearing aids/cochlear implants I experience migraines that may be triggered by sound I have a recent injury, fracture, or surgery I have a condition that makes lying flat uncomfortable or unsuitable I experience vertigo or significant dizziness I have a diagnosed cardiovascular condition I have another health condition that could affect my ability to participate comfortably None of the above

If you selected any of the above, please provide any information you believe I should know in order to make your session comfortable and appropriate.

You are responsible for seeking advice from an appropriately qualified healthcare professional if you are unsure whether Reiki, sound, vibration, or participation in a sound bath is appropriate for you.

Sound & Vibration

During a private Reiki + Sound session, I may use instruments including tuning forks, crystal singing pyramid, Tibetan singing bowls, and other therapeutic sound instruments. These produce sound and vibration. Some may be used around the body and, with specific permission, certain instruments may be gently placed on the body.

Are you comfortable experiencing sound and vibration close to your body?

Yes No I would like to discuss this first

Are there any sounds, frequencies, volumes, or instruments that you know make you uncomfortable?

Consent to Touch

Reiki may be offered with my hands lightly touching appropriate areas of the clothed body, or with my hands positioned above the body. My preferences may change at any time during the session, and I understand I may withdraw consent to touch at any time. Sensitive/private areas of the body are not touched as part of a Reiki treatment.

What is your preference?

I consent to appropriate gentle touch Hands-off Reiki only Please ask me before touching me during the session

I understand and agree

Tibetan Singing Bowl Consent

During some private Reiki + Sound sessions, I may recommend placing a Tibetan singing bowl gently on an appropriate area of the clothed body, such as the abdomen, so that its vibration can be experienced directly. This will only be done with your permission, and you may change your mind at any point.

Are you comfortable with a singing bowl being placed on your clothed abdomen/body if I believe it would complement your session?

Yes No Please ask me at the time

Reiki & Energy Work

I understand that Reiki is a complementary wellness practice traditionally based on concepts of energy and energetic balance. I understand that concepts such as chakras, meridians, qi, and energetic blockages are traditional or spiritual frameworks and are not established anatomical structures or medical diagnoses. I understand that experiences during Reiki vary considerably and that no particular physical, emotional, or energetic response is guaranteed.

I understand

Important Informed Consent

Please read each statement carefully.

I understand that Reiki, sound healing, and sound baths are complementary wellness practices intended to support relaxation, mindfulness, and general wellbeing. I understand that Live Right Wellness does not diagnose disease or medical or psychological conditions. I understand that Reiki and sound healing are not substitutes for medical care, psychotherapy, medication, or treatment provided by a licensed healthcare professional. I understand that I should not discontinue or alter prescribed medication or medical/mental-health treatment based upon a Reiki or sound healing session. I understand that no specific result, outcome, healing, or cure has been promised or guaranteed. I understand that individual responses to Reiki, meditation, sound, and vibration vary. I understand that I am responsible for communicating discomfort, pain, dizziness, emotional distress, excessive sound sensitivity, or any other concern during the session. I understand that I may request that an instrument be stopped, moved farther away, or not used. I understand that I may stop my participation or leave a session at any time.

Possible Experiences & Risks

Although Reiki and sound-based wellness sessions are generally intended to be gentle and relaxing, individual responses vary. Possible temporary experiences may include, but are not limited to: emotional responses; temporary discomfort from remaining in one position; light-headedness or dizziness; sensitivity to sound or vibration; headache; tingling, warmth, or other bodily sensations; unexpected memories or emotions; and temporary fatigue or feeling deeply relaxed. I understand that I should immediately tell the practitioner if I become uncomfortable.

I understand and voluntarily choose to participate.

Group Sound Bath Acknowledgement

For group participants: I understand that a group sound bath takes place in a shared environment and that sound levels, frequencies, and proximity to instruments may change throughout the experience. I understand that I am responsible for choosing a comfortable position and may sit up, move farther from an instrument, use hearing protection, or leave the room if necessary. I understand that the practitioner cannot continuously monitor every participant's individual response during a group session.

I understand and accept these conditions. Not applicable — I am attending a private session.

Personal Responsibility & Assumption of Risk

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that participation in Reiki, sound healing, and sound bath experiences is voluntary. I acknowledge that these activities may involve known and unknown risks and that individual responses to sound, vibration, touch, meditation, and relaxation cannot always be predicted. I voluntarily choose to participate and assume the ordinary and inherent risks associated with my participation. I agree to inform Live Right Wellness of any relevant change in my circumstances that may affect my safe participation in future sessions.

Release & Waiver

To the fullest extent permitted by applicable Arizona law, I voluntarily assume the ordinary and inherent risks associated with my participation in Reiki, sound healing, and/or group sound bath services. I release and hold harmless Live Right Wellness, Lucy Mitchell, and their respective agents, contractors, and representatives from claims arising from the ordinary and inherent risks of my voluntary participation, except to the extent such release is prohibited or unenforceable under applicable law. I understand that this agreement does not waive rights or claims that cannot lawfully be waived.

No Guarantee of Results

I understand that no representations, promises, or guarantees have been made regarding the results of Reiki, energy work, sound healing, or sound bath participation. I acknowledge that words such as healing, balance, energy, chakra, meridian, frequency, and vibration may be used within the context of complementary wellness practices and are not representations that a medical condition is being diagnosed or treated.

I understand and agree.

Photography & Marketing

This section is completely optional and is NOT a condition of participating. Private Reiki/Reiki + Sound sessions will not be photographed or recorded without separate express permission.

May Live Right Wellness photograph or record you during a group event for marketing/social-media purposes?

Yes No

Final Acknowledgement

By signing below, I confirm that I have read and understood this form; I have had the opportunity to ask questions and my questions have been answered to my satisfaction; I understand the nature of the services being offered and that participation is voluntary; I understand that I may withdraw consent or stop participating at any time; I voluntarily consent to receiving the services I have selected; and I agree to the assumption-of-risk and release provisions above.

Full Legal Name Electronic Signature (type your full name) Date By checking this box and electronically signing, I acknowledge that I intend my electronic signature to have the same effect as my handwritten signature.

For Clients Under 18

A parent or legal guardian must complete and sign this section.

Participant's Name Parent/Legal Guardian Name Relationship to Participant

I am the participant's parent or legal guardian and have authority to provide consent on their behalf. I have read the information above and consent to the minor's participation, subject to applicable law.

Parent/Guardian Signature Date