Client Intake Form - SEM Wellness

Consent / Privacy Notice / Release and Assignment/ Cancellation/Late fees

Name *

First

Last

Phone

Email *

Emergency Contact

Name and Phone #

Reason for session *

Have you ever had a Reiki session before? *

If yes, when was your last session?

Do you suffer from epilepsy? *

Do you consent to light touch? *

Are you sensitive to perfumes or fragrances? *

CANCELLATION POLICY | We understand that unanticipated events happen occasionally in everyone’s life. In our desire to be effective and fair to all clients, the following policies are honored: 24 hour advance notice is required when cancelling an appointment. This allows the opportunity for someone else to schedule an appointment. If you are unable to give us 24 hours advance notice you will be charged the full amount of your appointment. If you have pre-paid it cannot be applied to another appointment.

NO-SHOWS | Anyone who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a “no-show.” They will be charged for their missed appointment. If you are unable to give us 24 hours advance notice you will be charged the full amount of your appointment. If you have pre-paid it cannot be applied to another appointment.

LATE ARRIVALS | If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the “full” session. Out of respect and consideration to your therapist and other customers, please plan accordingly and be on time.

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, prescribe substances, 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 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 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. Privacy Notice: No information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18. *

Signature (Electronic)

I hereby acknowledge, I irrevocably authorize you and your representatives, (hereinafter “you”) to film, videotape, photograph and/or record me in connection with Michelle Calizo and to use such film, videotape, photography and/or recording any number of times in any manner or medium now or hereafter known including without limitation, for example, home video devices, audio records, broadcast television, cable, pay-per view- youtube, tiktok, etc… and in advertising and promotion of such uses for purposes of trade. You shall not be obligated to use any such film, videotape, photography and/or recording. 2) I hereby release and assign to you all rights, worldwide an in perpetuity, relating to such film, videotape, photography, and/or recording and their uses, including but not limited to, the sole and exclusive right to reproduce, distribute, broadcast, sell and otherwise exploit same by any means now or hereinafter known or developed, in whole or part, with the right to edit or modify and to secure copyrights in connection with the sale and advertising of the foregoing. *

Signature (Electronic) or N/A

Date signed

Month / Day / Year