DECLARATION UNDER PENALTY OF PERJURY

In consideration of receiving services of value from _________________________________ ,
I hereby declare under penalty of perjury that:

* My true and legal name is as signed below and not otherwise.
* I am not an employee, agent or investigator of any federal, state, or local governmental
agency, medical association, or law enforcement group or agency engaged for any purpose related
to this visit.
* No recorded transcript or transmission thereof is being taken of any conversation occurring
at this session.
* I have been informed and am aware that the above named practitioner is not licensed under the
laws of this state to practice any form of medicine.
* That the above named practitioner will neither diagnose nor prescribe for any condition or
problem from which I may appear to be suffering.
* That the above named practitioner suggests that, should I have any physical or mental
complaints, I should consult a licensed medical practitioner as to the nature and results of
any methods which have been employed at this time for the relaxing of the body or the
establishment of peace of mind within myself.
* I understand that the above named practitioner is a practitioner of Reiki (a spiritual practice)
and acting as a spiritual counselor following the teachings of his/her religious practices and
as such I am instructed not to request any diagnosis of my condition or request the
prescription of any drugs or medicines as such is not permitted by law.
* That the above named practitioner is relying on the power of Universal Life Energy to
intervene and render such assistance as may be needed in the way of spiritual counseling or the
use of divine energy to assist in the relaxing of my body, bringing peace to my mind, or
enhancing my well being.
* That said counselor has informed me and I understand that no guarantees or promises of cures
or alleviations of any complaints have or will be made to me and that any benefits which I
experience must come from within myself as I allow the Universal Healing Power of Reiki to make
whatever adjustments or corrections are necessary.

My name: ____________________________________
(please print clearly)

Address: ____________________________________

____________________________________

____________________________________

Phone number: _______________________________

Today's Date: _______________________________

My Signature: _______________________________

Witness: ___________________________________