About this template
This Reiki Consent Form is designed for energy healing practitioners to streamline their client intake process. It captures essential personal details, emergency contact information, and a comprehensive health history, including current medical conditions, medications, and recent surgeries. By gathering this data upfront, practitioners can tailor their sessions to the specific needs and safety requirements of each client.
Beyond basic intake, this template serves as a vital tool for establishing professional boundaries and informed consent. It ensures that clients are fully aware of the nature of Reiki treatment, its limitations, and the voluntary nature of the session. Using Doc2Form to deploy this as a Google Form allows practitioners to maintain organized, digital records that are easily accessible and secure, helping to foster trust and professionalism from the very first appointment.
Key features
- Comprehensive health history and medical intake section.
- Clear informed consent language for treatment transparency.
- Emergency contact details for safety and peace of mind.
- Mobile-friendly design for easy client completion.
- Automated data collection directly to your Google Drive.
Use cases
- New client onboarding for Reiki and energy healing practices.
- Pre-session health screening for massage and holistic therapists.
- Maintaining updated client records for recurring wellness sessions.
What this form collects
- Full Name (Short answer)Please enter your full legal name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Contact Information (Short answer)Provide your primary phone number and email address for appointment updates.
- Emergency Contact (Paragraph)Please provide the name and phone number of someone we can reach in an emergency.
- Medical History (Paragraph)Do you have any current medical conditions or health concerns we should be aware of?
- Medications and Supplements (Paragraph)List any medications or supplements you are currently taking.
- Recent Surgeries (Paragraph)Have you had any surgeries in the last 6 months? If yes, please describe.
- Allergies (Paragraph)Please list any allergies, including sensitivities to scents, oils, or materials.
- Informed Consent (Multiple choice)I understand that Reiki is a relaxation and stress-reduction technique. I understand that Reiki practitioners do not diagnose conditions or prescribe substances. I acknowledge that I am responsible for my own health and that I may withdraw consent at any time.
- Client Signature (Short answer)Please type your full name here to serve as your electronic signature.
FAQ
What is an informed consent form?
It is a document that outlines the nature of a service, ensuring clients understand the process, potential benefits, and their rights before agreeing to participate.
Why is a consent form important for Reiki?
It protects both the practitioner and the client by establishing clear expectations and documenting that the client has provided voluntary, informed consent for the treatment.
Can I customize this form for my practice?
Yes. Once you convert this template to a Google Form, you can easily add your own branding, specific clinic policies, or additional questions relevant to your unique healing modality.
How do I handle the client signature requirement?
Since Google Forms does not have a native signature field, we recommend adding a checkbox question where the client acknowledges their agreement, or using a third-party add-on for digital signatures.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.