Reiki Mastery Academy

Health Declaration & Informed Consent Form

Thank you for completing this Health Declaration & Informed Consent Form.

Your health, safety and wellbeing are important to us. This information helps us to understand any physical or emotional health considerations before you attend or participate in your session, course or event with us

Practices such as Conscious Connected Breathwork (CCB), Qigong, Meditation, Reiki and Sound Healing maybe included depending on the programme. Some activities may not be suitable for everyone, particularly those with certain medical or psychological conditions.

Please answer the questions honestly and completely. Your information will be treated confidentially in accordance with our Privacy Policy.

If you have any concerns, please contact us before attending so we can discuss them privately.

Are you aged 18 or over ?

Yes

Age requirement: Our events, sessions and courses are for adults aged 18 and over only.

Name of Event, Session or Course

Date of Event, Session or Course

Month

Day

Year

Emergency Contact - Full Name

Emergency Phone Contact

Health Declaration & Contraindications

If you selected any health conditions above, please provide relevant details, including whether the condition is current, controlled or requires medication.

Is there anything else about your physical or emotional health, or any recent changes in your wellbeing, that we should know to help ensure your comfort and safety during the session, course or event?

Are you currently taking any prescribed medication that may be relevant to your physical or emotional wellbeing during the session, course or event?

Yes

Prefer to discuss privately

If you answered Yes, please provide details of any relevant medication and what it is prescribed for. If you prefer, you may discuss this privately with the facilitator before the session, course or event.

Important Safety Information

Conscious Connected Breathwork (CCB) involves a continuous breathing pattern that can affect oxygen and carbon dioxide levels and may produce strong physical sensations or emotional experiences. Possible effects include tingling, dizziness, muscle tension, changes in body temperature, emotional release or altered awareness.

Full-intensity Breathwork may not be suitable for everyone, particularly those with cardiovascular conditions, high blood pressure, epilepsy, glaucoma, retinal detachment, pregnancy, recent major surgery, significant respiratory conditions or certain psychological or psychiatric conditions. If you have disclosed any health condition, are taking relevant medication or are unsure whether Breathwork is suitable for you, please contact us before attending. Medical advice or clearance may be necessary.

In some circumstances, a gentler, modified breathing practice may be appropriate, but this must be assessed individually. You may pause or stop participating at any time. Please inform your facilitator immediately if you feel unwell or uncomfortable. Breathwork is a complementary wellbeing practice and is not a substitute for medical or psychological treatment.

Wellbeing practices such as Reiki, sound healing, Qigong and guided meditation are generally gentle, but individual health conditions, injuries, sensory sensitivities or emotional experiences may affect your comfort or suitability. Please disclose any relevant concerns, including difficulties with movement or balance, sensitivity to sound or touch, or difficulty remaining seated or lying down comfortably. Activities may be adapted where appropriate. You may request adjustments, decline physical contact, rest or stop participating at any time.

Please also review our Health & Suitability Information for further details about each practice.

I confirm that I have read and understood the Breathwork & Wellbeing Safety Information above. I understand these modalities may produce physical and emotional effects, that I must disclose relevant health conditions, and that I may pause or stop at any time. I agree to contact the facilitator before participating if I have any concerns about my suitability.

Participation & Personal Responsibility

By participating in this session, course or event, I understand and acknowledge that:

My participation is entirely voluntary.
I am responsible for providing accurate and relevant health information.
I will inform the facilitator of any changes to my health or wellbeing before participating.
I may pause, rest, decline an exercise or stop participating at any time.
I will follow reasonable safety guidance and communicate any discomfort or concerns.
Some activities may involve physical sensations or emotional experiences.
Breathwork, Reiki, Qigong, Meditation and Sound Healing are complementary wellbeing practices and are not substitutes for medical, psychiatric or psychological treatment.
No medical diagnosis, treatment or cure is being offered.
The facilitator may recommend that I do not participate in an activity if there are safety concerns.
For online sessions, I understand that I am responsible for choosing a safe, suitable environment in which to participate, following the facilitator's instructions and stopping any activity if I experience discomfort or feel unwell.
I understand that the facilitator is not physically present to provide immediate assistance, and I agree to inform them of any relevant health concerns before the session.

I confirm that I have read and understood the Participation & Personal Responsibility information above, including the additional safety requirements for online sessions where applicable. I understand that my participation is voluntary, that I may stop at any time, and that I agree to follow reasonable safety guidance and communicate any concerns to the facilitator.

Health Declaration & Informed Consent

By signing this declaration, I confirm that:

I have read and understood the information relevant to the session, course or event that I am participating in.
I have answered the health questions honestly and to the best of my knowledge.
I understand that complementary wellbeing activities may involve physical or emotional experiences and certain inherent risks.
I have had the opportunity to disclose relevant health concerns and ask questions before participating.
I understand that I may pause, decline an activity or withdraw at any time.
I agree to follow reasonable safety guidance and communicate any discomfort or concerns.
I voluntarily consent to participate in activities for which I have been assessed as suitable.

I acknowledge the inherent risks associated with voluntary participation. Nothing in this declaration excludes or restricts any legal rights or liability that cannot lawfully be excluded, including liability for death or personal injury caused by negligence.

I confirm that I have read and understood the Health Declaration & Informed Consent Form information above. I acknowledge the inherent risks associated with participation and voluntarily consent to take part in the activities for which I have been assessed as suitable.

Privacy & Health Information Consent

The information you provide in this form may include sensitive personal health information.

Reiki Mastery Academy / Hilary Kingston will use this information to assess your suitability for participation, identify relevant health and safety considerations, communicate with you where necessary, and maintain appropriate records.

Your information will be treated confidentially, stored securely and accessed only where necessary for these purposes.

Health declarations, consent forms and related records may be retained for up to seven years where justified for insurance, legal or record keeping purposes, subject to applicable data protection requirements.

For further information about how your personal data is handled and your rights, please read our Privacy Policy:

I explicitly consent to Reiki Mastery Academy / Hilary Kingston collecting, storing and using the health information I have provided to assess my suitability for participation and manage relevant health and safety considerations, as explained above and in the Privacy Policy. I understand that I can contact support@reiki-mastery.com to ask questions about my information or withdraw my consent, subject to any lawful grounds for continued retention.

I confirm that I have read and understood the Privacy Policy and understand how my personal information, including health information, will be collected, used and stored.

I confirm that I have read and agree to the Terms & Conditions applicable to my session, workshop or event.

Final Declaration & Signature

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that completing this form does not automatically confirm my suitability for every activity.

I understand and agree to inform my facilitator before attending if I have any relevant health conditions, injuries, mobility limitations, physical or mental / emotional wellbeing concerns, or if my health or circumstances have changed since completing this form. I understand that I can discuss any concerns or adjustments privately with my facilitator before the session begins.

Participant Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date of Signature

Month

Day

Year