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Client Intake Forms

Please complete the below two forms prior to your Reiki Therapy session. If you have completed these  forms at a prior session, there is no need to complete again unless information has changed. 

Client Intake Form

General Information

Have you experienced a Reiki session before?
Are you sensitive to Aromatherapy or smells in general?
Yes
No
Do you have sensitive skin?
Yes
No
Would you prefer hands-on or hands-off ?
Hands-On
Hands-Off
No Preference
Are you interested in a self-healing Reiki class?
Yes
No
Maybe

Colorado Disclosure Form

Sacred Lotus Reiki & Natural Healing


Brenda Dulin, Reiki Master Teacher

brenda@sacredlotusreiki.com

As a Complementary and Alternative Health Care Practitioner, I am not licensed, certified or registered by the state of Colorado as a health care professional. I am not a licensed medical physician and do not diagnose, treat or prescribe remedies for the treatment of disease.


The services I perform, whether in person, by mail or by phone, are at all times restricted to complementary and alternative health care services intended for the maintenance of the best possible state of general well-being. I am prohibited from performing surgery or any invasive procedure, administer or prescribe x-ray radiation, prescribe prescription drugs, use general or spinal anesthetics, administer ionizing radioactive substances, use a laser device that punctures the skin, perform enemas/colonics unless board certified, practice midwifery, practice psychotherapy, perform spinal manipulation, practice optometry, directly administer medical protocols to a pregnant woman or a person who has cancer, practice dentistry, set fractures, practice massage therapy, provide a conventional medical disease diagnosis or recommend the discontinuation of a course of care recommended by a health-care professional.


Further, you understand the services I offer and the use of Reiki and Meditation are not intended to be a substitute for medical or psychological treatment and they do not replace the services of health care professionals. You agree and understand it is your responsibility to consult with your health care provider for any specific health care problems.

 

By signing this document you understand I am offering my services solely as a complementary and alternative health care practitioner and our relationship is not to be construed as medical treatment, psychotherapy, psychological counseling, or any type of therapy, nor is it a substitute for these services.

 

I am prohibited from treating children less than two years of age. In order to treat a child who is between 2-8 years of age, I must have a written, signed consent of the child’s parent or legal guardian.

 

The services I, Brenda Dulin, provide are as follows: Reiki Treatments and Meditation and may include crystals, pendulums, aromatherapy, tuning forks, and other complementary healing arts techniques.

 

My professional degrees, training, experience, credentials and qualifications are as follows:


Reiki: White Light Reiki I with Barbara Kajan Scott in 2012, In 2020, I took Usui Reiki I and II with Lisa Guyman and completed Usui Reiki Master and Teacher Training courses in 2021 with Lisa Guyman. I am a member of the International Association of Reiki Professionals (IARPReiki.org).

 

Meditation: Primordial Sound Meditation with Lisa Guyman in 2008.


Please complete the information below.

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Brenda Dulin | Reiki Master Teacher | Owner

6015 Lehman Dr | Colorado Springs, CO | 719.828.2501 | brenda@sacredlotusreiki.com

2020-2025 | Sacred Lotus Reiki & Natural Healing LLC | Colorado

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Sacred Lotus Reiki & Natural Healing LLC
6015 Lehman Dr. #202
Colorado Springs, CO 80918
719-828-2501

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Disclaimer: Results may very from person to person. Services are not intended to diagnose, treat, cure, heal, or prevent any disease and does not constitute medical advice.

©2020-2024 Sacred Lotus Reiki & Natural Healing LLC | Colorado Springs | Colorado

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