Reiki Treatment Consent Form

(O Ver este formulario en español)

Please read and e-sign below.
I give my consent to participate in Reiki treatment sessions with/at Back to Heart Center and understand that the services provided are intended to provide relaxation and stress reduction. In-person Reiki treatments are given fully clothed on a massage table but are not considered massage therapy.

I understand that the services provided during this Reiki session are in no way a substitute for traditional medical treatment or advice. I am fully aware that my Reiki practitioner will not offer any diagnosis or recommend any medical treatment or medication. Reiki is a complement and support to traditional medical and psychological care.

As with any other therapy, long-held imbalances or conditions can require multiple sessions in order to activate the system’s natural, regenerative abilities.

I agree and understand that my participation in any Reiki Session is voluntary and that, at any time during the Session, I can choose to end my participation. 

I also understand that Reiki's effects can extend past the treatment session and that I may experience physical, energetic, emotional shifts or sensations during the 48 hours following the session. 

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 I share during any session at Back to Heart Center is strictly confidential and will not be shared with any other person or entity without my written permission.

Finally, I understand that by providing this informed consent, I am assuming full responsibility for participating in my Reiki Treatment Session and I hold harmless my chosen Reiki Practitioner, Back to Heart Center, and, if applicable, the facility/location where the services are provided.

Social Justice at Back to Heart Center: As a white-owned business in an affluent New England town, we aim to offer equitable access to our services in our local community, offering pay-what-you-will and barter opportunities, no-questions-asked, to the Black, Indigenous, Latino, and broader diasporic communities. In support of domestic and sexual violence survivors in Berkshire County, we are in partnership with the Elizabeth Freeman Center and offer our services, free of charge, to their clients and staff. You can read our Social Justice statement and policies here.

PAYMENT: Back to Heart Center accepts all major credit cards, checks, cash, Venmo and the Berkshires’ local currency BerkShares. Payment is expected after each session. 

CANCELLATION & REFUND POLICY

• There are no refunds on Reiki services that have already been provided.

• If you need to cancel or reschedule an appointment, kindly give us 24 hours notice.

By filling out the form below, I consent to all of the above.