New Client Form Please complete the form prior to your session. Client Name * First Name Last Name Your Current Location (City/State for US clients, for clients living outside of the US, please list your City/Country) * Cell Phone Number * (###) ### #### Regarding future appointments, would you like to receiving text notifications and communications at this phone number? (Charges from your cellular carrier may occur) Yes, you can text me No, I prefer email notifications only Both text and email are permitted Email * Emergency Contact: (Name/Relationship) * Emergency Contact's Phone Number * (###) ### #### How did you hear about Zero Point Reiki? Ex. Yelp, Google, Thumbtack, Internet search, referral + name of the person who referred you. Would you like to receive promotions or events held by Zero Point Reiki in the future? (Via Email) (This will add you to our mailing list which you can opt-out of anytime, we will never sell your information, that's super bad juju) Yes Please! No thank you. Have you ever had a Reiki session before? Yes No If YES, about when was your last Reiki session? Never had Reiki before Less than a month ago Between 1 - 6 months ago 6 months to a year ago Way over a year ago Don't remember Number of previous Reiki sessions you have had and how was your experience? (Optional question) Do you have a particular intention or area of concern to address during your Reiki session? * I understand that Reiki is a simple, gentle, hands-on energy technique that is used for stress reduction and relaxation. I understand that Yilin Frion-Lee does not diagnose conditions nor does she prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that Reiki does not take the place of medical care. Yilin Frion-Lee recommends that I see a licensed physician or licensed health care professional for any physical or psychological ailment I may have. I understand that Reiki can complement any medical or psychological care I may be receiving. I also understand that the body can heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions to facilitate the level of relaxation needed by the body to heal itself. COVID-19 Liability Waiver (For in-person sessions only) If you are booking an in-person session, you're acknowledging that an inherent risk of exposure to COVID-19 exists and can't not hold Zero Point Reiki liable for injury. For in-person session, you are required to wear a mask. To cancel or reschedule your appointment if you are experiencing flu like symptoms (Coughing, sneezing, fever). By submitting this New Client Form you are agreeing to the terms of this waiver. Zoom Recording Agreement (For Remote sessions only) All remote sessions are conducted via Zoom, the energy healing portion of the session will be recorded and shared with the client only. Please note that the content of the recording is limited for personal usage of the client ONLY. Clients are prohibited from publishing contents of the video or use it for monetary means. By submitting this New Client From you are agreeing to the agreement. Client Signature First Name Last Name Date MM DD YYYY If under 18 parent signature here First Name Last Name Date MM DD YYYY Thank you for submitting the New Client Form. I am looking forward to working with you soon. Have a beautiful day.
