Consent
I understand that Reiki/Energy Medicine uses simple, gentle energy techniques that are used for relaxation and healing of the mind, body and spirit. Techniques will generally consist of various forms of light or deeper touch and of movement of the practitioner’s hands within my body’s energy field. While they are gentle and considered non-invasive, it is possible that physical or emotional after-effects may occur after my energies have been stimulated and adjusted. In some instances, deeper pressure is used to move energies that may be blocked or congested in a particular area of the body, and this may cause some pain or discomfort. Dizziness, nausea, or anxiety are relatively unusual but not unheard of side-effects to
energy work. If I am uncomfortable with being touched or with any of the procedures being used, I will immediately tell my practitioner. I understand that Reiki/Energy Medicine practitioners do not diagnose conditions, nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional.
I understand that neither Reiki nor Energy Medicine take the place of medical care. It is recommended that I see a licensed health care professional for any physical or psychological care I may need. I understand that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation and balance needed by the body to heal itself. I understand that Energy Medicine is effective energy work that requires MY active involvement between sessions. My practitioner will show me how to establish energy patterns that optimize body, mind and spirit. Reinforcing these new patterns through the regular practice of energy exercises my practitioner will recommend and teach is MY part of the bargain.
Minors
If you are under 18 years of age please be aware that I will need your parents or legal guardians permission to meet with you for energy work. If you are over 12 years of age the State of Illinois states that you can decide if your parents/legal guardians shall have access to your session records. If they agree, I will provide only general information about our work together unless I feel there is high risk that you would seriously harm yourself or someone else. In this case, I will discuss this with you first and then notify them of my concerns.
Sessions,

Fees and Cancellations
I understand my initial session will be 2 hours in length and will be $150.00 with subsequent in-person sessions being 90 minutes for $125.00.
I understand distant sessions can either be 60 minutes for $75.00 or 120 minutes for $150.00.
I understand that payment is due at time of service.
I understand that I must give at least 24 hours notice for any cancellations.
I understand that I may be charged the full amount of the session for any missed appointments or for those cancelled in less than 24 hours.
I understand if I am going to be more than 15 minutes late for a session I need to call as soon as possible.
I understand I will be charged $100.00/hour for my practitioner to prepare for and attend any meetings with other professionals I have authorized OR for any legal proceedings I am involved with where my practitioner may be called to attend even if called by another party.
Confidentiality/Privacy Policy
I understand that my session records will be kept in a locked environment with only the practitioner having access.
I understand that I may see and receive copies of my session records at any time. (Please allow 3-5 business days to process a records request.)
I understand that no client information with be shared with any third party without my written consent.*
*Because Mary Walters is a licensed Registered Nurse in the State of Illinois she has a mandatory obligation to report to the appropriate authorities:
– Any witnessed violence against another individual
– Any suspicion of or discovery of abuse or neglect of a minor, or an elderly or disabled person
– Any suspicion of or discovery of any plans of self-harm or harm to others
I understand that in certain legal proceedings, particularly those involving child custody or those in which my emotional condition or treatment is an important issue, a judge may order my practitioner to testify.
Confidentiality is not protected when a judge makes such an order or in certain other legal procedures. It is suggested that I consult with an attorney if I am involved in a legal situation where confidentiality may be at issue.
I understand that if more than one person from my family is treated by the same practitioner what I say and what occurs in my sessions can be shared with other family members. If confidential information is a concern I understand it is better for each family member to work with a different practitioner.
Rights and Responsibilities of Client and Practitioner
I understand I have the right to be treated with respect and dignity and to be treated in a safe and caring environment.
I understand that I will have an opportunity to have all of my questions and concerns addressed in a timely manner.
I understand that I and my practitioner both have the right to stop a session at any time if either of us feels uncomfortable.
I understand that I and my practitioner both have the right to terminate our work together at any time.
I understand that it is my responsibility to notify my practitioner of changes in my demographic information as well as any changes in my health status.
I understand that my practitioner will notify me as soon as possible of any changes in scheduling, fees, or polices and notify me well in advance of any anticipated lengthy absences.
I understand that if I have any complaints or am unhappy with the way our work together is proceeding, I will talk to my practitioner so that they can respond to my concerns directly. Such concerns will be taken seriously and be met with care and respect. If I believe that my practitioner has been unwilling to listen and respond, or that they have behaved unethically, I can register a complaint about their behavior with the organization that certifies them as an Eden Energy Medicine Practitioner: Innersource, 777 East Main Street, Ashland, OR 97520, 541-482-1800, www.innersource.org, ethics@innersource.org.
My signature below indicates that I have read the information in this document, understand it fully, have discussed any questions or matters of concern with my practitioner and/or others, and agree to abide by its terms during our professional relationship.