The information on this form is confidential and will not be disclosed to any other party without your written consent unless in an emergency and it is not possible to obtain your consent.
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Name:
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Date of Birth:
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Phone Number:
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Email Address:
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Health History:
Current Health: status and any conditions/diagnoses
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Past Health: status and condition
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Current Medications:
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Current Supplements:
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Treatment History: Please list any and all prior alternative health treatments, energy balancing
and relaxation techniques you have received and your assessment of the outcome
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Current Concerns: Reasons for receiving these sessions
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I understand that the distance Reiki and energy healing sessions provided by Dylan Mariah and Dave Cornell are a stress reduction and relaxation technique. I acknowledge that the sessions I receive are for the purpose of helping me relax and are not a substitute for needed medical care. I also understand that my body has the ability to heal itself and that its ability to do so is enhanced by relaxation and stress reduction. I understand that to receive the full benefit of any kind of supportive therapy I need to commit and be open to receiving this assistance. In order to get the greatest benefit from these sessions, I understand that I need to contact Dave Cornell and/or Dylan Mariah via email on a daily basis in order to provide an update on any perceived changes I notice regarding my Current Health Concerns.
Client's Initials: Date:
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