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Hospital Reiki Session Request Form

Volunteer Reiki Practitioners are available Wednesday morning from 10:00am 1:00pm and Saturday afternoon from 1:00pm -4:00pm.

Although we do everything possible to accommodate every request , our time is limited. Thus, if possible submitting requests at least 24 hours prior to a scheduled volunteer shift is suggested. Once a request is received, volunteers will verbally ask if more sessions are desired. Thus, only one online request is required per visit.

Hospital Session Request Guidelines:
1.
* Staff, Patients and Family Members of patients may fill out this Online Request Form
2. Staff recommendation and signature on CAET Reiki Program Form
3. Verbal request from patients and family for repeat Reiki sessions.

* Recommended

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Required Field: *

* Name of Patient:  
* Unit Number:  
* Room Number:  
* The patient is:  

Contact Person

* Name:  
* Email:  
* Phone:  
* Relationship to patient:  
* This request is:  
Is there anything else
you would like us to know?:
   

CONFIDENTIALITY NOTICE: The information contained in this e-mail is privileged and confidential, and is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are notified that any disclosure, copying, distribution, electronic storage or use of this communication is prohibited. If you received this communication in error, please notify us immediately by e-mail, attaching the original message, and delete the original message from your computer and any network to which your computer is connected.

       
 
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