Client Intake Form

Client Name(required)

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Thank you for your request for guidance and spiritual healing. Please describe the issues for which you are seeking relief.(required)

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Services:  I provide Reiki Healing, Reference Point Therapy, Melchizedek Healing, Magnified Healing and  Shamanic Healing including soul retrieval, extraction, power animal retrieval, instruction in energy, and  other spiritual work needed to deal with emotional, physical and spiritual issues.  I am also a Pranic  Healer. You are free and able to discontinue the energy healing at any time. Also if I feel that the service is  not achieving the desired results I will inform you in a timely manner.

Professional Ethics: I will perform these services only with your advance permission and in accordance  with ethical guidelines and strict confidentiality and non-interference with others’ freedom of will. Some  Energy techniques are best performed while in physical contact with the client; however, I will not touch  you without your permission.  Most services are performed over skype, and sometimes over telephone.

Donation: Services are by donation in accordance with your means and the value you place on what you  receive. A suggested donation is $75 to $125 per session

Legal Notice

I am not licensed, certified or registered by the State of Florida as a health care professional. You should  discuss any of my recommendations about your health with a primary care board-certified physician. I do  not carry liability insurance covering injuries caused by my acts or omissions. You agree not to hold me  liable for any consequences of my services. I do not perform invasive medical procedures or medical  services requiring a professional license, use X-ray or radiation devices, practice midwifery, massage or  spinal manipulation, prescribe or administer prescription substances, offer medical protocols to pregnant  women or cancer patients, perform, provide psychotherapy as defined in C.R.S. §12-43- 201, or treat  children under two. Children age 2-8 require parent permission for treatment and should be under the  care of a licensed pediatric health care provider.   Energy transformation does not take the place of  recommendations of your medical practitioner.

Please type your full name if you have read and understood the information above: (required)

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To make an appointment, via Skype or in-person please send completed form to firstreikimaster@hotmail.com indicating your contact information and availability.