Alternative Therapies Legislation in Colorado- Effective June 5, 2013 – Includes Reiki
DISCLOSURE STATEMENT AS REQUIRED UNDER SB-215 FOR
COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS IN COLORADO
1. Your Name
2. Your Address
3. Your Phone
As a Complementary and Alternative Health Care Practitioner, I am not licensed, certified or registered by the state of Colorado as a health care professional. I am not a licensed medical physician and do not diagnose, treat or prescribe remedies for the treatment of disease. The services I perform, whether in person, by mail or by phone, are at all times restricted to complementary and alternative health care services intended for the maintenance of the best possible state of nutritional health. I am prohibited from performing surgery or any invasive procedure, administer or prescribe x-ray radiation, prescribe prescription drugs, use general or spinal anesthetics, administer ionizing radioactive substances, use a laser device that punctures the skin, perform enemas/colonics unless board certified, practice midwifery, practice psychotherapy, perform spinal manipulation, practice optometry, directly administer medical protocols to a pregnant woman or a person who has cancer, practice dentistry, set fractures, practice massage therapy, provide a conventional medical disease diagnosis or recommend the discontinuation of a course of care recommended by a health care professional. I am also prohibited from treating children less than two years of age. In order to treat a child who is between 2-8 years of age, I must have a written, signed consent of the child’s parent or legal guardian:
The services I provide are as follows: _________________________________.
My professional degrees, training, experience, credentials and qualifications are as follows:
I took ______Reiki classes with _________________ I have been practicing Reiki since _____________.
If you have registered with the IARPREIKI.org include a statement here about that.
If you have liability insurance for Reiki include a statement here about that. Example text: I carry liability insurance applicable to any injury caused by an act or omission in providing complementary and alternative health care services.
A copy of this disclosure statement will be kept on file for at least two years after the last date of service.
*As my client, you should discuss any recommendations I provide with your Primary Care Physician, Obstetrician, Gynecologist, Oncologist, Cardiologist, Pediatrician or Pediatric Health Care Provider, or other Board-Certified Physician.
Name of Client Signature of Client
Address of Client City, State, Zip Code
Phone Number E-Mail Address
Date of Birth Date of First Visit