Informed Consent for Energy Healing Services
I understand that the State of Arizona does not offer a license specifically mentioning the practice of Reiki/Energy Medicine, and Reiki/Energy Medicine is not specifically regulated by any Federal or State regulatory agency, nor have uniform educational standards or requirements with respect to Reiki/Energy Medicine been adopted by any such agency.
I understand that a Healing Practitioner does not diagnose or treat illness or disease, or act as a physician, and Reiki/Energy Medicine does not substitute for diagnosis or treatment from a qualified health practitioner for illness, injuries, or other medical conditions. Any discussion of health conditions is incidental to healing of energetic imbalances and should not be misinterpreted as a form of diagnosis or treatment. I understand that Reiki/Energy Medicine is used to assess and correct imbalances in the body’s energies and energy fields using techniques that incorporate physical touch.
I understand that no published scientific research has offered significant data concerning the safety, efficacy, or mechanism of Reiki/Energy Medicine. I understand that there is no guarantee of any particular result, or any specific outcomes from the use of Reiki/Energy Medicine. While some individuals may experience immediate benefits and some may experience a short term “healing crisis”, the risks and benefits of Reiki/Energy Medicine have not been scientifically established.
I understand that my experiences during a Reiki/ Energy Medicine session are confidential, subject to the usual exceptions that I may instruct my Practitioner to release information to other health care practitioners.
The full fee of $130 for a 60 minute session is payable at the time of the session unless other arrangements have been made in advance. 24 hour cancellation notice by phone, is required to avoid being charged.
I have read and understand that the above disclosure regarding services offered by Amy Schill/Healing Options, LLC. I understand that she is not a licensed physician and that her services are not licensed by the State of Arizona. I understand that she is not trained to diagnose illness or handle medical emergencies. I further understand that it is my responsibility to maintain relationships with conventional health care providers as appropriate for myself, or my dependents. I agree that I am ultimately personally responsible for my health care. I knowingly, voluntarily and intelligently consent to use the services offered by Amy Schill/Healing Options, LLC, including the use of touch. I agree to release and indemnify her and her agents from and against any and all claims, which I, or my representative may have for any loss, damage or injury arising out of or in connection with my use of her services. This form is the sole and complete description of the professional relationship, is interpreted under Arizona law, and Arizona will be the forum for any claims filed under or incident to this form. If any portion of this form is held invalid, the rest of the document will continue in full force and effect. All of my questions about these services have been answered to my satisfaction.