Please check any of the symptoms or physical problems listed below that you are currently experiencing. Allergies
Arthritis
Respiratory/Lungs
Weakness
Jaw/TMJ Pain
CV/Heart
Diabetes
Scoliosis
Sprains/Strains
Insomnia
Vision/Contacts
Numbness
Tingling
Epilepsy
Headaches
Dizziness
High/Low Blood Pressure
Fatigue
Other
None
Are you currently pregnant or postpartum (within the past 6 months)? Yes
No
Do you have any history of seizures, epilepsy, or fainting spells? Yes
No
Do you experience panic attacks or have a history of anxiety disorders? Yes
No
Have you been diagnosed with cardiovascular issues (e.g., high blood pressure, heart disease)? Yes
No
Have you been diagnosed with bipolar disorder, schizophrenia, or any other condition requiring psychiatric care? Yes
No
Are you currently taking medication for anxiety, depression, or mood stabilization? Yes
No
Do you have asthma or any other respiratory conditions? Yes
No
Do you have any injuries or physical limitations we should be aware of (e.g., spine, joints, surgeries)? Yes
No
Thank you for saying yes to yourself. We’re honored to hold this sacred space for your healing and transformation. To ensure a safe and aligned experience, we ask that you read and acknowledge the following: 1. Nature of Services I understand that this retreat may include Reiki, meditation, breathwork, movement practices (such as yoga or Pilates-inspired sessions), somatic healing, and emotional exploration. These experiences are intended to support relaxation, stress reduction, and energetic alignment. I acknowledge that Reiki and all energetic practices offered are complementary healing arts—not a substitute for licensed medical or psychological care. Retreat facilitators do not diagnose conditions, prescribe medication, or offer medical advice. 2. Personal Responsibility I affirm that I am participating voluntarily and am responsible for my own physical, emotional, and mental well-being. I understand that I may experience emotional release or physical sensations as part of the healing process, and I agree to listen to my body and honor my boundaries throughout the retreat. I agree to consult my healthcare provider for any medical or psychological concerns before and after the retreat. 3. Assumption of Risk I understand that any physical or emotional activity carries inherent risk. I assume full responsibility for any injury, loss, or discomfort I may experience and release the retreat facilitators, hosts, and property owners from any and all liability related to my participation. 4. Commitment to the Process I understand that healing is a personal journey that requires commitment and openness. I recognize that lasting results come through consistent self-inquiry, energetic alignment, and willingness to grow. I accept that multiple sessions or experiences may be beneficial over time. 5. Media Release. Photographs or video may be taken for future promotional purposes. Acknowledgement By submitting this form, I acknowledge that I have read and agree to the terms of the above consent and liability waiver. I confirm that I have read, understood, and agree to the terms of this consent form. I participate of my own free will and release all parties involved from liability.
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