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Services from Universal Healings LLC

In Person / Distant Reiki Consent Form

I hereby voluntarily request and consent to receive Energy services whether distant or in-person from Universal Healings LLC. from Universal Healings LLC, Cassandra Pierce (Thistle) Reiki Master Teacher and verify that I am over 18 years of age.

If I am under the age of 18, I certify that my parent or legal guardian is with me while reading and reviewing this form and consent to receive distant or in-person Reiki from Universal Healings LLC.

I understand and acknowledge that no guarantees have been made to me as to the effects of such services. I further understand and acknowledge that in no way are these services meant to be construed by me as a diagnosis or treatment of disease, but rather as a means of supporting relaxation, pain management, and overall well-being for my personal healing.

I have received an explanation and description of what a session will entail and have been given an opportunity to ask questions to help understand what is involved.

I understand that I may refuse or stop the services at any time. If at any time I wish to stop the session for any reason I will communicate my needs to Cassandra Pierce (Thistle) in which she will abide by my wishes immediately. I understand that payment is collected during the online scheduling phase of my session and no refunds will be given unless my session is canceled within 24-hour notice.

Insurance

I acknowledge that Universal Healings LLC does not accept insurance or file insurance claims.

Cassandra Pierce (Thistle) is a certified Reiki Master Teacher with both medical and spiritual training, Traditional Hindu Chakra Specialist, Practitioner of Access Consciousness the Body Process, and a Certified Wellness coach of the Detoxification Body Process, Certified Aromatherapist, and Kundalini Yogi. Cassandra is not a licensed physician nor are any of the services offered through Universal Healings is not licensed by the state of Wisconsin.

Fees and Payment

Fees charged for a session from Universal Healings LLC Services and is collected during the online scheduling phase of my session and no refunds will be given unless my session is canceled within 24- hour notice. Gift cards are exempt from fees and expire after 1 year of purchase. Prior arrangments for payment must be approved, if traveling or having multiple persons at one location. Prior arrangements are approved or denied from Cassandra.

Privacy

I have been informed that all client information and records provided during a Universal Healings LLC session will be kept confidential except under circumstances as detailed in Wisconsin Statutes or federal laws and regulations. Information may not be released to individuals or agencies without my signed authorization, except in those legal situations as noted. Practitioners are required by law to report, or cause to be reported, the threat of serious harm to self or others. Client files are maintained in strict confidence, in accordance with applicable state and federal laws and professional standards.

I authorize that material from my Universal Healings LLC session may be discussed in confidence with an appropriate mentor for purpose of consultation, education or support.

All information will be handled professionally and confidentially. Such discussions enable my practitioner to render better service and increase their effectiveness in my sessions.

I understand that my personal privacy will always be maintained, and I may be instructed to remove my shoes and/or jewelry during session to help facilitate the energy flow of for my treatment.

I understand that Reiki Healing is not a substitute for medical treatment and or medications, and I will concurrently work with my qualified medical professional for any condition I may have. I am advised that if I show any symptoms of illness, I should consult my Personal Care Provider. I am aware that my Reiki Master Teacher, Cassandra Pierce (Thistle), is not a trained medical professional and does not diagnose illness or disease, does not prescribe medication and is not a trained counselor or therapist.

Client Signature OR Parent/Legal Guardian Signature:

 

*I certify I am under the age of 18 and my parent/legal guardian consents me to this service*

Date: May 23, 2024




First Participant's Name

First Name*

Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

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


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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