PEACE OF MIND INTEGRATIVE SERVICES, LOVE BLOSSOMS LLC, NJ

RACHEL LEE CRONIN |  CERTIFIED 200 RYT, REIKI HEALER, AROMATHERAPIST

CLIENT INFORMATION & WAIVER

NAME: _____________________________________________________________________________________   (PLEASE PRINT*)

ADDRESS:_____________________________________________________________________________CITY:_________________________________________

STATE:__________ ZIP:______________________

PHONE: ____________________________________ DOB: ____________________

EMAIL: ________________________________________________________

Would you like to join a Mindful Newsletter? Stay connected for future healing events and be inspired, Don’t Worry, you can unsubscribe at anytime.    Yes, Please____ No, Thanks____

Medical(Injuries, physical limitations, ailments, surgeries, allergies, restrictions*)     Yes____ No____ 

If Yes, Please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

*EMERGENCY CONTACT (Name/Phone#): ________________________________________________________

• Reiki is a Japanese technique for stress reduction and relaxation that helps promote Divine healing. It is administered by a Reiki practitioner, sometimes using healing hands on touch, based on the idea that is unseen, a “Life Force Energy” that flows through us, sharing in energy. Are you comfortable with being touched or adjusted during your Session?  Yes____ No____

• Aromatherapy is the use of fragrant essential oils to promote healing and well-being for therapeutic purposes, through inhalation or bodily application (as by massage). Are you ok with the use of Aromatherapy in your Session? Yes____ No____     If you are sensitive to specific aromas please describe:____________________________________________________________________________

___________________________________________________________________________________________________________________________________________ 

By this Waiver, I agree to participation in Yoga classes, Aromatherapy, Workshops, and/or Reiki Healing organized by Love Blossoms LLC, such participation includes meditation techniques, yogic breathing, and performing various Yoga postures. By signing my name below, I acknowledge that my participation in yoga classes or any other exercise class exposes me to a possible risk of personal injury. I am fully aware of this risk and hereby release Love Blossoms LLC, and/or any persons who may teach/heal through Love Blossoms LLC, from any and all liability, negligence, or other claims, arising from, or in any way connected, with my participation in yoga, healing, and the use of essential oils. My signature further acknowledges that I have signed this Agreement freely, voluntarily, and under no duress, and this waiver is binding on me, my heirs, my spouse, my children, my legal representatives, my successors, and my assigns to release considerable future legal rights. My signature verifies that I am physically fit to participate in yoga classes and/or massage, reiki healing, or any other form of healing and/or exercise classes, and a licensed medical doctor has verified my physical condition for participation in these forms of healing treatments and classes. If I am pregnant, or become pregnant, or am post-natal, my signature verifies that I am participating in yoga, or any other exercise or healing modality, with my doctor’s full approval as well as my own. I realize that I am participating at my own risk. I understand that Reiki is a hands-on, gentle touch/technique used for stress reductions & relaxation and does not diagnose, treat, or prevent any conditions or ailments and does not interfere with treatment by a licensed medical professional. I understand that Yoga, Reiki & Aromatherapy can compliment any medical or psychological care I may be receiving but is not in place of medical evaluation or treatment. I acknowledge that long-term imbalances of the body may sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to naturally heal itself.

Signature:      __________________________________________________               Date:  ___________________

 Guardian’s Signature if under 18: _________________________________________________

Photography Permission:

With this signature below, I hereby grant Love Blossoms LLC, and it’s legal representatives, permission to use and publish photographs or video images of me, or in which I may be included, for any purpose authorized by Love Blossoms LLC, including but not limited to: website use, advertising use, and personal. This grant includes the right to modify and retouch images in discretion of Love Blossoms LLC. I understand that the circulation of such materials could be worldwide and that there will be no compensation. 

Signature: ______________________________________________Guardian’s Signature if under 18:______________________________ 

Thank you for allowing me to be of Service, Namaste :)