Initial Intake & Consent (Reiki)

Date/Time: [Encounter date and time]

Practitioner Name: [Practitioner full name]

Credentials/Certifications: [Credentials and Reiki certifications]

Organization: [Organization name / Not applicable]

Client Name: [Legal name]; Preferred: [Preferred name]

Date of Birth: [DOB / Not collected]

Client ID: [Client ID / Not used]

Encounter Type: Initial Intake

Modality: [in-person / distant / hybrid]

Location: [Clinic address / Telehealth platform / Offsite description]

Source of Information: [client / parent/guardian / interpreter]

Interpreter Used: [yes / no] (If yes: [Language], [Interpreter name])

Contact Information

(If any item is not provided, document "Not provided" or "Client declined" rather than leaving blank.)

• Primary Phone: [Phone number / Not provided / Client declined]
• Permission to Text: [yes / no / Client declined]
• Email: [Email address / Not provided / Client declined]
• Preferred Contact Method and Time: [Phone / Text / Email]; [Best days/times]
• Voicemail Consent: [yes / no]
• Text Consent: [yes / no]
• Email Consent: [yes / no]
• Safe Contact Instructions: [Client's instructions for safe communication / None specified]

Emergency Contact

• Name: [Emergency contact name]
• Relationship: [Relationship]
• Phone: [Phone number]
• Authorize Contact in Urgent Situations: [yes / no]

The practitioner will contact emergency services (911) for medical emergencies. Reiki is not a substitute for emergency medical care.

Reason for Visit & Goals

[Client's stated reason for seeking Reiki] (Include a direct quote if offered: "[Client quote]". Use client-reported language without diagnostic interpretation.)

• Areas of Focus/Concern: [Body areas, emotional or spiritual intentions as stated by client]
• Goals for Today's Session: [Client-centered, observable goals] (If no specific goals: "Seeking general relaxation and well-being.")
• Goals Over Time: [Ongoing client-centered goals]
• Expectations or Concerns: [Client expectations or concerns about Reiki]

Prior Experience with Reiki & Complementary Therapies

• Reiki Experience: [none / some / frequent]; [What has been helpful or unhelpful in past sessions]
• Related Modalities: [Massage / Meditation / Acupuncture / Other / None] (Only include if client chooses to share.)

Health & Safety Information

(Collect only information relevant to providing a safe session. Use client-reported language; avoid diagnostic interpretation.)

• Current Medical Conditions: [Client-reported conditions relevant to comfort/safety]
• Recent Surgeries or Injuries: [Client-reported details affecting comfort/positioning]
• Pregnancy Status: [yes / no / not applicable / client declined] (Only if relevant to positioning.)
• Allergies/Sensitivities: [Linens, fragrances, latex, or other sensitivities]
• Medications/Supplements: [Client-reported items / Client declined / None disclosed]
• What Helps You Feel Safe and Comfortable: [Client response] (Do not require disclosure of trauma history.)

Safety Screen

(Ask briefly and document. If any red flag is present, defer the session and provide appropriate referral.)

• Chest pain: [yes / no]
• Severe shortness of breath: [yes / no]
• Recent syncope: [yes / no]
• Acute neurological symptoms: [yes / no]
• Active suicidal ideation: [yes / no]

If any item is "yes": Session deferred. Referral: [911 / Emergency Department / Urgent Care / Contact primary clinician]. [Brief documentation of what was advised]

Session Preferences & Boundaries

• Touch Consent: Hands-on touch [yes / no / only with permission each time]; Hands hovering [yes / no]; Ask before each hand placement [yes / no]
• Areas to Avoid Entirely: [List areas]
• Areas Requiring Explicit Check-in: [List areas]
• Pain/Tender Areas Affecting Positioning: [List areas]
• Clothing: Client remains clothed during the session.
• Comfort Items: Blankets [yes / no]; Bolsters [yes / no]; Temperature [cooler / neutral / warmer]
• Positioning Preference: [supine / prone / side-lying / seated]; Accommodations: [Mobility or accessibility needs]
• Environmental Preferences: Fragrance-free [yes / no]; Music [none / soft / client preference], Volume [low / medium]; Lighting [dim / moderate / bright]; [Silence / Guided relaxation]; Essential oils [none / specify if consented]
• Other Boundaries or Requests: [Client-stated boundaries]

Informed Consent for Reiki

Description of the Session: Reiki is a relaxation-focused practice in which the practitioner places hands lightly on or hovers above the body. The client remains fully clothed. Privacy is maintained using appropriate draping and room setup. Experiences vary; sensations may include warmth, coolness, tingling, or no particular sensations. No specific outcome is promised.

Potential Benefits: Relaxation, comfort, and stress reduction. (Benefits are not guaranteed.)

Potential Risks or Burdens: Possible emotional release or temporary distress, discomfort from positioning, or sensory discomfort if preferences are not adequately tailored. Please inform the practitioner of any discomfort so adjustments can be made.

Alternatives: You may decline Reiki today, request modifications, consider other wellness modalities, or seek medical or mental health evaluation if symptoms warrant.

Client Rights: You may decline any technique, request changes, or stop the session at any time.

Scope and Limitations: The practitioner does not diagnose, prescribe, or provide medical treatment. Reiki is not a substitute for medical or mental health care. Clients are encouraged to continue care with licensed clinicians as appropriate. No outcomes are guaranteed.

Consent Affirmation: "I have had the opportunity to ask questions. I understand the information provided and consent to receive Reiki as described."

Privacy & Confidentiality Acknowledgment

Information shared is kept confidential within the practice, with limits. Common exceptions include: with your written authorization, as required by law, or to prevent imminent serious harm.

(If HIPAA covered entity) Notice of Privacy Practices: [Acknowledged / Refused to sign / Unable to obtain acknowledgment]. Documentation of attempt: [Brief note if not acknowledged]

Signatures

Client Signature: [Client signature] Date/Time: [Date/time]

Parent/Guardian (if minor): [Name and signature] Relationship: [Relationship] Date/Time: [Date/time]

Practitioner Signature: [Practitioner signature] Date/Time: [Date/time]

Consent Status: [Written consent obtained / Verbal consent obtained per policy / Session deferred / Session not performed]

(If client declined to sign: [Reason offered, if any]. If session deferred or not performed: [Rationale and referrals provided].)

Practitioner Notes (Internal)

(For practitioner use only. Keep factual; avoid speculative or diagnostic content.)

• Accommodations to Implement: [Positioning, fragrance-free, lighting, temperature adjustments]
• Touch/Boundary Summary: [Hands-on vs hovering, areas to avoid, check-in points]
• Planned Session Structure: [Session length, positioning, communication style, breaks]
• Referrals/Recommendations: [Only if discussed and provided]