Earth Angel Reiki
Informed Consent for Treatment
Practitioner(s): Christina Lane, RN, RMT; Amy Hatch, CPNP; Jean Rocca, RN, RM
Services: The services to be provided by the above-named practitioner(s) to the client may include any or all of the following: Reiki, Angel Messenger Card Readings, Tapping, other available holistic treatments not listed here, as determined jointly prior to sessions. All information shared is strictly confidential and the client is encouraged to ask questions at any time. The client acknowledges that treatments involve close proximity and/ or physical touch from the practitioner to the client only. The client is encouraged to express any feelings of physical or emotional discomfort or unease should they arise. The client acknowledges that sessions are not guaranteed to cure, treat or provide relief from any disease or symptom. The client releases the practitioner from liability in the unlikely event of any physical or emotional injury or distress that may occur.
Disclosure: Although a practitioner may hold a board certification or license in Nursing, it is important that the client is aware the practitioner will not be functioning in this role for the purpose of treatment sessions. General guidance on health and well-being may be given. However, the client acknowledges the practitioner is not a licensed counselor, nutritionist or massage therapist. All concerns regarding medical or mental health conditions should be directed to the client’s regular health care practitioners.
Appointments: Sessions are 90 minutes in length. Out of mutual respect, a 24-hour cancellation notice is requested. We understand situations arise and we will do our best to accommodate a mutually agreed upon rescheduled date and time. If you arrive late for your scheduled appointment, we will do our best to accommodate. However, in respect for all, we do not guarantee that you will receive your full treatment if you are late to your scheduled appointment.
Communications: Acceptable forms of communication include text, call, e-mail, or messaging through social media and/or trinitylane.us. Please allow up to 24 business hours for a response. Clients are encouraged to reach out again if no reply is received within that time frame.
Privacy: Any information shared between practitioner and client is strictly confidential. I am aware that practitioners are mandated reporters in the commonwealth of Massachusetts and this confidentiality may be broken if the client is at risk of harming themselves or others. Any communication between practitioner and any third party requires expressed written consent of the client or parents/ guardian if the client is under 18, unless required by law.
Payment: No payment is required for this 90-minute complimentary Reiki session from Earth Angel Reiki.
I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Reiki practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. It is recommended that I see a licensed provider or licensed healthcare professional for any physical or psychological ailment I may have. I understand that any wellness discussions and/or recommendations that arise during a reiki session must be reviewed and consented to by a licensed physician prior to initiating any change in my health and wellness. I understand that Reiki can only complement any medical or psychological care I may be receiving, but does not take the place of traditional medical care. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal itself. I have read this statement of policy and understand its contents. I have asked any questions I may have about these policies and voluntarily consent to holistic sessions with Christina Lane, RN, RMT; Amy Hatch, CPNP, RM, and Jean Rocca, RN, Rm, under the terms described above and acknowledge that I have the right to terminate this agreement should I no longer wish to receive holistic treatments from Christina Lane, RN, RMT., Amy Hatch, CPNP, RM, and/or Jean Rocca, RN, RM. I acknowledge that I have been offered a copy of HIPAA (Notice of Privacy Practices for Protected Health Information). (Please see copy of HIPAA below)
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Client Printed Name Client Signature Date
If under 18, signature of parent/guardian: ___________________ Printed Name: ________________
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Practitioner Printed name Practitioner Signature Date
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Practitioner Printed name Practitioner Signature Date
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Practitioner Printed name Practitioner Signature Date
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION:
No information about any client will be discussed with any third party without written consent of the client or parent/guardian if the client is under 18, unless required to do so by law. Any information from a Reiki session between practitioner and client may be kept as physical and/or electronic records to facilitate treatment of stress reduction and/or relaxation for each client. All personal information will be kept strictly confidential to the best of the practitioner’s ability.