Remote Consent (Additional Form Required for Distance Reiki)

(Do not download; will be emailed to the address on file for signature)


Distance Reiki requires remote sessions and involves the use of secure interactive videoconferencing devices and equipment and that enable energy practitioners to deliver their services to clients when both are located at different sites. Please read this carefully and let me know if you have any questions. When you sign this document, it will represent an agreement between us.

  1. I understand that the same standard of care applies to a remote session as it applies to an in-person visit.

  1. I understand that the laws that protect privacy and the confidentiality of personal information apply to remote sessions.

  1. I understand that I will not be physically in the same room as my practitioner. I will be notified of and my consent obtained for anyone other than my practitioner.

  1. I understand that my personal information may be shared with other individuals for scheduling and billing purposes.

  1. Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Lotus Petals Therapy, its agents or the practitioner named above from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

  1. If I am using insurance:

  • I understand that my insurance carrier will have access to my medical records for quality review/audit.

  • I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my remote session.

  • I understand that health plan payment policies for remote sessions may be different from policies for in-person visits.

  1. Risks to confidentiality: As remote sessions take place outside of your office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end, I will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device.

  1. Issues related to technology: I understand that there are potential risks to using technology, including service interruptions, interception, and technical For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

  1. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my practitioner or I may discontinue the remote session and make other arrangements to continue the visit.

  1. Right to Refuse: I understand that I have the right to refuse to participate or decide to stop participating in a remote session, and that my refusal will be documented in my client record. I also understand that my refusal will not affect my right to future care or

  1. I may revoke my consent at any time by contacting my energy practitioner at 571-989-0529.

  1. Fees: If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

  1. Records: I understand that my practitioner will maintain a record of our session in the same way they maintain records of in-person sessions in accordance with their policies.

  1. I understand that this document will become a part of my personal


By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to remote sessions shared with me in a language I understand; and (3) I am located in the state of                                 [insert state] and will be at                                                            [insert location, i.e. home, office] during my remote session(s).



 (Updated 4 January 2021)

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