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This is a waiver for Reiki services provided by Kristen Kennedy of Affirmations & Innovations LLC. 

I understand that Reiki is delivered while the client is either seated in a chair or lying supine on a massage table. It is not a form of massage and the client remains fully clothed. I understand that Reiki is a relaxation and stress reduction technique that works on the physical, mental, energetic, and spiritual components of the body. I also understand that Reiki is an energy healing methodology that includes the laying on of hands to a person who remains fully clothed on non-invasive parts of the body.

I further understand that Reiki practitioners do not diagnose or prescribe substances, nor interfere with treatment of a licensed medical professional. Any recommendations made before, during, or after this session are merely suggestions and the patient is soley responsible for their actions after a session.  Reiki practitioners are not currently licensed in the US. I understand that Kristen Kennedy is not a licensed physician, and that Reiki is complementary to and separate from medical services licensed by the state. However, I understand that Kristen Kennedy of Affirmations & Innovations LLC has completed a Reiki Certification program. 

I understand that Reiki is being provided by Kristen Kenendy of Affirmations & Innovations LLC at my request. I hereby release Kristen Kennedy and Affirmations & Innovations LLC from all liability and understand that she is not responsible for the outcome of the session.

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you previously received Reiki treatment?*
No
Yes
I understand that Kristen Kennedy and Affirmations & Innovations LLC retains the right to discontinue Reiki services at any time, even during a session, without explanation. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are a safe space for all involved and that clients must maintain professionalism and respect for the Reiki practitioner, including Kristen Kennedy and Affirmations & Innovations LLC, at all times. *
I acknowledge and agree to the above statement.
I understand that Reiki sessions are private, but that Reiki practitioners, including Kristen Kennedy and Affirmations & Innovations LLC, are not held responsible under HIPAA. *
I acknowledge and agree to the above statement.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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