Before your first session.
Please complete this form before your first session — it helps me prepare for your visit and is required before we begin. Below you will also find the disclosure statement that the State of Colorado requires complementary and alternative health care practitioners to provide, so you can read it at any time, even before booking.
If you prefer paper, you can download and print the form and bring it to your session:
Disclosure statement.
As required under SB-215 for complementary and alternative health care practitioners in Colorado.
Practitioner: Evolene Premillieu
Address: 4737 White Rock Circle Apt F, Boulder, CO 80301
Phone: +1 720 401 7397
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 general well-being. 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.
I provide Reiki services and Sound Therapy with Himalayan Singing bowls with the following experience:
I have been practicing Reiki extensively since 2009. I have taken all levels of Reiki training between 2009 and 2013 with Reiki Master Christine Veyrenche.
I have taken level 1, 2 and 3 classes with the Atma Buti school in 2026.
All my services are covered by professional liability insurance provided by Massage Magazine Insurance Plus (MMI+).
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.
Consent to receive treatment.
By signing this form, I confirm that I have read and acknowledged the disclosure statement required by the state of Colorado and I hereby agree to receive Reiki and/or Sound Therapy with Himalayan Singing bowls. I agree to fully release and hold harmless Aiki Natural Healing practitioners from and against all claims of liability of whatsoever kind of nature arising out or in connection with my session except in the case of gross negligence or malpractice. It is my choice to receive alternative health care and I am willing to be open to experience changes throughout my healing journey.
The intake form.
Filling this out online counts as your signature: typing your full name at the end, together with the date and the consent checkbox, acts as your electronic signature.