Informed Consent & Scope-of-Practice Statement (Reflexology)

Client Name: [Client name]

Date of Birth: [Date of birth]

Date/Time of Consent: [Date and time]

Setting: [in-person / remote / electronic portal]

Service Location: [Location or platform name]

Practitioner Name and Credentials: [Practitioner name and credentials]

Decision-Maker and Capacity

Consenting Party: [Client self / Legal representative / Parent or guardian for minor]

• If surrogate: [Surrogate name, relationship, and basis of authority] (Only include if legal representative or guardian is consenting.)
• Minor assent: [Assent obtained / Assent not obtained / Not applicable] (Only include for minor clients.)

Capacity Attestation: [Practitioner statement on consenting party's ability to understand information, ask questions, and make voluntary decision] (If capacity was questionable, document observed limitations and actions taken.)

Interpreter/Communication Accommodations: [Language, interpreter name and ID, modality, and any other accommodations used] (Only include if applicable.)

Description of Reflexology Services

What is reflexology: Reflexology involves applying pressure to specific points on the feet and/or hands with the goal of supporting relaxation and general well-being. It is a non-invasive, touch-based complementary wellness service.

What to expect during a typical session:

• Areas of contact: [feet / hands / both]
• Products: [Lotion or oil used / No products used / Unscented options per client preference]
• Positioning: [Seated / Reclined / Other positioning]
• Approximate session length: [Duration in minutes]

Scope-of-Practice Acknowledgments

(Client checks or initials each item.)

• [ ] I understand reflexology is supportive and complementary. It is not a substitute for medical diagnosis or treatment.
• [ ] I understand the practitioner does not diagnose conditions, prescribe treatments, provide medical prognosis, or treat specific diseases.
• [ ] I understand outcomes are not guaranteed and individual experiences vary.

Touch Consent and Preferences

• Consent to touch areas: [ ] Feet [ ] Hands [ ] Both
• Areas to exclude per client preference: [Areas to avoid] (Only include if client specifies exclusions.)
• Pressure preferences: [Light / Moderate / Firm]
• [ ] I understand I may pause or stop the session at any time for any reason.
• Stop word or signal: [Chosen word or signal] (Only include if applicable.)

Benefits, Evidence Limitations, and Alternatives

• Potential benefits: Clients may experience relaxation, stress reduction, improved sense of comfort, and general well-being.
• Client-reported goal: [Client's stated goal in their own words] (Only include if client states a goal. Document as client goal, not clinical target.)
• Evidence limitations: Scientific evidence for specific health claims related to reflexology is limited, and effectiveness varies by individual.
• Alternatives discussed: [Alternatives reviewed with client] (Examples: choosing not to receive reflexology today, self-care approaches, consulting a licensed healthcare provider for medical concerns.)

Risks and Health Disclosure Acknowledgment

• Common possibilities: Temporary tenderness or soreness, fatigue, emotional response, lightheadedness, and skin sensitivity if products are used.
• Health information to disclose: Acute injuries; infections or open wounds on treatment areas; circulation concerns; recent surgery; pregnancy; implanted devices; allergies or sensitivities; or any condition that could affect suitability.
• [ ] I confirm I have provided accurate health history and will update the practitioner about any changes.
• Health intake form: [Completed and reviewed / Not completed] (If completed, reference the form.)
• Client declined to provide health history: [Client's decision and whether services were deferred] (Only include if client declines disclosure.)

Confidentiality

Client information is treated as confidential and used for providing services, coordination, and records. Limits to confidentiality include disclosures required by law and safety exceptions per organizational policy.

Records storage and access: [Storage type, location or system, and who may access]

Communication preferences: (Client selects any they consent to. Note potential privacy risks of unencrypted communication.)

• [ ] Phone voicemail at: [Phone number] — May leave detailed message: [yes / no]
• [ ] Text message at: [Phone number] — Appointment-related only: [yes / no]
• [ ] Email at: [Email address] — Scheduling details only: [yes / no]

Questions and Understanding

Client questions and practitioner responses: [Summary of questions asked and responses provided] (If no questions, document that the client had an opportunity to ask and declined or had none.)

Understanding check: [Method used and outcome] (Only include if teach-back or other verification performed.)

Scope clarifications: [Misunderstanding expressed and clarification provided] (Only include if client expressed misunderstanding about scope, such as requesting disease-specific treatment.)

Consent Decision

• [ ] Consents to proceed
• [ ] Consents with limitations: [Limitations specified]
• [ ] Declines services today: [Reason and next steps discussed]
• [ ] Withdraws consent after initially consenting: [Time and context]
• [ ] Deferred by practitioner: [Reason and referrals or next steps]

Signatures

Client/Surrogate Signature

• Printed name: [Name]
• Signature: [Signature]
• Date/Time: [Date and time]
• If surrogate: [Relationship and basis of authority] (Only include if surrogate signed.)

Practitioner Signature

• Practitioner name: [Name]
• Signature: [Signature]
• Date/Time: [Date and time]

Method of consent capture: [Written paper / Electronic signature / Verbal consent]

• If verbal consent: [Summary of consent statement and witness name and title] (Only include if consent was verbal.)
• [ ] Client declined to sign but provided verbal consent (Document summary and witness.)

Copy provided to client: [Paper / Electronic / Portal access / Client declined copy]

(If capacity assessment, health disclosure, or consent outcome is not addressed in the encounter, flag as incomplete documentation requiring follow-up. Omit any section or field that does not apply rather than inserting placeholders.)