Client Consent Form: All Reiki Services

About Lotus Petals Therapy

Lotus Petals LLC (dba Lotus Petals Therapy, the “practice”) provides its customers with access to energy healing, related training and the products to sustain those services.  Our mission is to provide you with the transformative experience of energy healing, empower you with self-healing techniques and provide you with the tools to develop life and wellness sustaining habits. Our practice is insured through the Energy Medicine Professional Association and all Lotus Petals Therapy Practitioners (employed and contracted) are required to abide by the Code of Ethics developed by the International Association of Reiki Professionals.


About Me (or Your Practitioner’s Training and Experience)

My name is [Name of Practitioner] and I am certified in the tradition of Usui Reiki Ryoho Gakkai, as a Master and Teacher. Usui Reiki Ryoho Gakkai is an eastern lineage that also goes back to its founder, Mikao Usui, but stayed in secrecy in Japan until the 1980s. In its original form, Reiki was presented by Mikao Usui as a simple method of self-healing, mindfulness and spiritual development. My goal is to stay true to the original teachings of Usui although I will align my services to match the energy needs of my clients. 


Although I am certified, my services do not require a license in the state of Virginia, but I am an ordained, as required by many other states. My original certifications were obtained through the International Reiki Organization and include USUI REIKI RYOHO MASTER, USUI REIKI TEACHER and CRYSTAL REIKI TEACHER. However, I maintain my professional credentials through training and membership in the Healing Touch Professional Association, Energy Medicine Professional Association, the International House of Reiki and International Association of Reiki Professionals.


Having practised and studied related philosophies for over 10 years, I decided to offer my services to the public in 2019.  I do not diagnose or treat disease and I am not a physician. Reiki sessions are not intended to substitute for the medical expertise and advice of your health care provider(s). If you have an ongoing medical condition, I encourage you to discuss any decisions about my treatment or care with your health care provider.



Basic Definition of Reiki:

Reiki is an evidence-based biofield energy healing modality that has been shown to effectively relieve pain and anxiety and support the body’s natural healing process. The National Institutes of Health’s (NIH) National Center for Complementary and Integrative Health classifies Reiki as a mind-body approach and Complementary Health Therapy. The NIH has engaged in randomized controlled trial and studies to evaluate the findings of published Reiki research.


Reiki is often referred to synonymously with healing touch and energy healing because they all serve as holistic, complementary and integrative energy-based approaches to health and wellness. Many of these traditions stress that balancing these energy fields can assist the body, mind and spirit in moving it towards and maintaining overall wellness.


Trained Reiki Practitioners use their hands to gently restore balance to the clients’ energy system using a light touch or with the practitioner’s hands near the client’s body. This modality can also be offered in a non-local or remote setting.


Description of a Session

During a session, the practitioner will gently place their hands on or above the person’s fully clothed body noting any sensations or imbalances to assess the energy field. The appropriate energy healing technique is then chosen which 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 energy healing. 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 colours. 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 energy healing is effective for physical and mental relaxation, pain management, anxiety and stress reduction, and increasing one’s sense of vitality. Clients 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 the legal limitations of my profession preclude me from making diagnoses or claims regarding your specific results. I can provide you with a list of research studies which have been done on energy healing since the early 1990s.


Reiki can be used in combination with conventional medical treatments to facilitate and speed healing. Improving the flow of energy around the body can enable relaxation and sleep, reduce pain, detox negative energy and improve overall well-being. Reiki has no known negative side effects however it is helpful if you align your intention positively.


Financial Terms and Conditions:


Client and customer payments are considered due to Lotus Petals Therapy when the appointment is scheduled. A non-refundable scheduling fee will be charged as a deposit ("non-refundable deposit"). Your deposit will allow you to make schedule changes up to 24 hours before your appointment. 


You can access your invoice from the confirmation email sent to the email address you provide. The invoice will include the balance due, minus the non-refundable deposit.  (Please check your junk mail for an email from "Acuity," our service provider.)


Payments not received in accordance with payment terms may result in appointment cancellation.  Refunds, minus the non-refundable deposit, and schedule changes can be made up to 24 hours before your scheduled appointment. Cancellations made less than 24 hours of a scheduled appointment or 'no-shows' will be charged the full price of the session.

Confidentiality and Client Rights:

Your experiences during our sessions are confidential, and you have a right to view your files upon written request. Those files are maintained in accordance with HIPAA privacy and security procedures regarding the handling of personal and confidential information. Remote sessions are held, and files are exchanged using a HIPAA-compliant platform.  Confidentiality is subject to the following exceptions:
  • You may instruct me to release information to other health care practitioners in writing.
  • 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).
  • 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.
  • Your confidentiality is always subject to the usual exclusions dictated by state and federal laws and regulations.



I have read and understand the above disclosure regarding the services offered by my Practitioner, [Name of Practitioner] and the related financial terms and conditions.

I understand the nature of the services being provided and have otherwise discussed them with my Practitioner. I understand 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 my Practitioner is not a licensed physician and that her services are not licensed by the state of Virginia. 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 understand that my participation is voluntary and at all times, I may choose to end my participation. 

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 Virginia and other federal laws and regulations. 

I understand that by providing this informed consent I am assuming full responsibility for my services and I hold harmless both the Lotus Petals Therapy practitioner and the facility/location where the services are provided. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Lotus Petals Therapy and/or [Name of Practitioner] from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

By accessing and using this service, I accept and agree to be bound by the terms and provision of this agreement. In addition, when using these particular services, I understand I am subject to any posted, terms, policies, guidelines or rules applicable to such services. Any participation in this service will constitute acceptance of this agreement.

My questions have been answered to my satisfaction regarding what I might expect from this session. I document my full consent to use the services offered by [Name of Practitioner] by signing below:

(Updated 4 January 2021) 

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