CLIENT INTAKE FORM FOR CHILDREN UNDER 18Important Note: All information provided is private and confidential. No information about any client will be shared with any third party without written consent from the parent or guardian.Child's Information: Child's Full Name: * Sex * Date of Birth: (D/M/Y) * Parent/Guardian Information: Full Name of Parent/Guardian: * Mobile or Home Phone Number * Email * City * Sex * Relationship to Child: * Emergency Contact Information: Emergency Contact Name Emergency Contact Phone Number Health Information Is your child currently under the care of a physician? Yes No If yes, please provide the physician's phone number: Please list any health issues or requirements we should know about (including allergies, health restrictions) Is your child taking any medication? Yes No If yes, please list Does your child use recreational drugs? Yes No If yes, please specify Healing Experience Has your child ever had a healing session before? Yes No How would you describe your child's experience with healing? Did they notice any results? Yes No If yes, please describe Is your child sensitive to touch? (In-person only) Yes No Consent and AcknowledgmentI, the undersigned parent/guardian, understand that the Reiki and healing sessions provided by Psychic Newsha involve a natural method of energy balancing aimed at stress reduction, relaxation, and healing for my child.I acknowledge that:These sessions are not a substitute for medical treatment and do not interfere with the treatment my child may receive from a licensed medical professional.I take full responsibility for my child's health care and maintenance.Nothing communicated by Psychic Newsha is intended to diagnose, prescribe, or treat any medical condition.I have disclosed all relevant information regarding my child's health that may affect the services provided.If my child experiences any discomfort during the session, I will ensure they voice their concerns immediately.Complete relaxation is often beneficial for healing, and long-term imbalances may require multiple sessions.I must provide at least 24 hours' notice if I wish to cancel the appointment and receive a refund. I understand my child can request to stop the session at any time, but this may not entitle us to a refund.I have read and understood the terms and conditions outlined above.By signing below, I acknowledge and fully agree with all the above information.Parent/Guardian Signature date (D/M/Y) * Please tick this box to confirm your agreement. * TICK THIS BOX AS YOUR SIGNATURE. Thank you for your cooperation. I look forward to supporting your child on their healing journey. Submit
