Reflexology Client Intake Form

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Reflexology Client Intake Form

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Last updated July 11th, 2023

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A reflexology client intake form is a questionnaire completed by clients to help reflexologists diagnose and treat a health concern. It allows clinics to collect a new client’s information, including their contact details, symptoms, and current health condition. Completing the form is an important step in ensuring the reflexologist has the information necessary to provide proper treatment.

Reflexology/Zone Therapy

Reflexology (or zone therapy) is an alternative treatment where pressure is applied to points on the feet, hands, or ears. It is held that specific points in these areas correspond to other body parts, which can be treated by applying pressure accordingly. Reflexology is often sought out for pain relief and other therapeutic purposes.

Intake Form Overview

  • Personal information. Details the client’s contact information, occupation, and emergency contact number.
  • Health information. Used to specify the client’s health condition, whether they take any medication, and a self-assessment of their lifestyle habits (e.g., sleep quality, nutrition, exercise habits, etc.)
  • Treatment information. Collects information on the client’s symptoms, concerns, and any areas of discomfort.
  • Acknowledgment. Includes a disclaimer holding the clinic harmless for any injuries, and fields for the client’s signature and signing date.

Reflexology Regulation

The regulation of reflexology varies widely across the United States. Some states require individuals to complete a state-approved reflexology course to be licensed, though not all states provide or require licenses. Many states govern reflexology under the same laws as massage therapy, requiring applicants to meet the state’s massage therapist requirements to practice reflexology. In contrast, other states exempt reflexologists from massage therapist requirements or have not set any laws governing either practice.

In general, only certification courses approved by the American Reflexology Certification Board (ARCB) are accepted by states that require reflexologists to be certified.