Consent form | Energy work with Anastasia

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Welcome!

Please read thoroughly and fill out this consent form honestly prior to participating in any session with me.

Thank you,

Anastasia

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Full name *

Birth name (if different than above)

Date of birth *

RRRR

I've booked a ___________ session with Anastasia: *

Reiki

shamanic healing ceremony/ceremonies

workshop

Povinné

If you've booked a shamanic ceremony: 1) is this your first experience? 2) have you done one before? and 3) if you have, when was your last? If applicable, please write answers below or proceed to next question.

I consent to pre-session instructions and follow-up being shared by ________. Note: Day-of session notes/instructions will be sent via text regardless of preference chosen here. *

telephone call

text

Povinné

My email is: *

My telephone number is: *

I have/had the following medical conditions and am currently taking these medications; this includes substance use and frequency: *

Medical history

Clients are responsible for disclosing their medical history, including medication and substance use, to Anastasia Koutalianos prior to a session.

Cancellations

Cancelled sessions require 24 hour notice, or you will be charged the full fee.

Record keeping

I keep consent forms and session notes for seven years; your health information will not be disclosed without your consent.

Benefits and outcomes of energy work

These treatments are powerful and can uplift and empower. That said, these sessions cannot guarantee healing or resolve or reversal of any kind.

Please be mindful that Reiki and shamanic ceremonies can induce discomfort in the body, be it physical, emotional, mental and/or spiritual (aka a a healing crisis). After a session, clients may experience sadness, guilt, anxiety, anger, frustration, loneliness, helplessness or other negative emotions, and may recall unpleasant memories. Should you have concerns or hesitations, do not book a session.

I have outlined my medical history, medication and substance use honestly without exclusion and omission.

I read, understand and agree to the information, policies and risks described in this consent form, and release Anastasia Koutalianos from any professional liability should a healing crisis occur.

Povinné

Today's date *

RRRR

Full name (signature) *

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