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: ___________________________________
