Healing Hearts Coaching Services, LLC
INFORMED CONSENT FORM for REIKI
My Status and Scope of Practice:
Hello, my name is Noelle Young Ellis and I am an Certified Reiki-One Practitioner. Reiki is a gentle, complementary, energy based approach to spiritual health and healing that can assist in bringing a body to its natural ability to heal. I do not diagnose or treat disease and I am not a physician. These sessions are not a substitute for diagnosis or treatment from a qualified health practitioner for illnesses, injuries, or other medical conditions. My services are not licensed by the state of Maine and my practice is guided by the Energy Medicine Professional Association Code of Ethics and Standards of Care.
Basic Definition of Reiki:
Reiki is an energy therapy in which practitioners consciously use their hands in a heart-centered and intentional way to support and facilitate physical, emotional, mental and spiritual health and healing. Reiki is "spiritually guided life-force energy".
Reiki is a holistic, complementary and integrative energy based therapy that is accomplished through the practitioner’s use of contact and/or non-contact touch and a heart-centered state of being. The healing traditions of many cultures emphasize the importance of subtle energy systems that flow through and around the human body, affecting its health and vitality. Many of these traditions stress that balancing these energy fields can assist the body, mind and spirit in moving towards and maintaining wellness.
Description of a Session:
During a session (which can vary in length averaging thirty to sixty minutes), I will gently place my hands on or above the person’s fully clothed body noting any sensations or imbalances to assess the energy field. I then choose a Healing Touch technique that is appropriate for your needs. This may include light physical touch or sweeping hand motion above the body. There is a high likelihood that you will experience the relaxation response during the session. A feedback discussion will follow. People have many different responses to Healing Touch. Some clients feel nothing at all. Others describe sensations of moving energy, deep relaxation, feelings of being supported and nurtured, or visions of images and colors. Some patients experience an emotional release such as tears; some have what they consider to be a spiritual experience or they may develop insight into specific areas of their lives.
Benefits of Reiki:
Recent research studies suggest that Reiki and other forms of Healing Touch are effective for physical and mental relaxation, pain management, anxiety and stress reduction, and increasing one’s sense of vitality. Clients of Healing Touch typically report experiencing the relaxation response and often report an increased sense of well-being and peace. Many have reported positive experiences that have helped them better cope with illnesses, medical protocols for treatment of medical conditions and depression but I can make no specific claims regarding the results you may experience from a Healing Touch session. Clients may request a list or summary of the numerous research studies done on Healing Touch since the early 1990s.
Healing Touch is a noninvasive energetic technique, still being researched by traditional science, and currently has no known detrimental side effects.
My Energy/Educational, Training and Experience:
• I hold a Reiki-One certification from the Dave Watson’s Reiki Academy of Natural-Attunement.
• I have completed a 9-month, 100+ hours, Essential Energetics Mentorship Program, including hands-on training with Haley Merchant, Certified Brennan Healing Science Practitioner and Sarah Tewhey, L.Ac & co-founder of 54 Herrick Integrative Medicine Clinic in Southwest Harbor, Maine.
• I have studied with Sue Frederick, career intuitive, speaker and author of Bridges To Heaven. In 2016, I completed her Grief Intuitive Coach coursework to become a certified professional Grief Intuitive Coach.
• I hold a traditional B.A. in Anthropology from Mount Holyoke College.
Your experiences during our sessions are confidential, and you have a right to view your files upon written request. Confidentiality is subject to the following exceptions:
1. You may instruct me to release information to other health care practitioners in writing.
2. I may release information if subpoenaed or otherwise legally obligated or reasonably allowed to do so (Including circumstances where there is clear and imminent danger to yourself or another person).
3. Your confidential personal file is kept in a secure location and is retained for 4 years after you suspend services after which time all information will be destroyed in a proper manner.
4. Your confidentiality is always subject to the usual exclusions dictated by state and federal laws and regulations.
ACKNOWLEDGEMENT, CONSENT, CLIENT PRIVACY RIGHTS
I have read and understand the above disclosure regarding the services offered by Noelle Young Ellis.
We have discussed the nature of the services to be provided including information that Reiki is a holistic complementary and integrative energy based therapy that is accomplished through the use of contact and/or non-contact touch. I understand that she is not a licensed physician and that her services are not licensed by the state of Maine. I understand it is my responsibility to maintain a relationship for myself with a medical doctor, if I so desire. I further understand that the above named is not trained to diagnose illness, make recommendations involving pharmaceutical drugs or surgery, or handle medical emergencies.
I have read and understand the above disclosure regarding privacy policies and confidentiality, and that experiences during these sessions are confidential, but subject to the usual exceptions governed by laws of the State of Maine and other federal laws and regulations.
Except in the case of gross negligence or malpractice, I or my representative(s) agree to full release and hold harmless Noelle Young Ellis from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).
I have been informed that Noelle Y. Ellis will neither diagnose nor prescribe for any condition that I might have nor does she make an specific claims regarding results from the Reiki sessions that I receive.
My questions have been answered to my satisfaction regarding my Reiki practitioner’s background, a Reiki session, and what I might expect from this session.
I fully consent to use the services offered by Noelle Y. Ellis by signing below:
Signed: ________________________________ Date: ____________
Print Name: _________________________________