Informed Consent for Yoga Therapy

Informed Consent for Yoga Therapy

In Balance Health Yoga
Informed Consent outlines in writing the client and therapist's plan and guidelines for treatment. Please read the following carefully and be sure to ask any questions/concerns that you may have regarding the contents of this document.
I am a certified yoga therapist in private practice, working with adults and adolescents with a special interest in working with individuals dealing with emotional health challenges and stress. My approach integrates yoga practices of mindfulness, breathing exercises, meditation, yoga postures, somatic movements, yoga education, and therapeutic touch.

I understandI do not understand
IN PERSON SERVICES My goal is to keep my clients and myself safe and healthy. Face masks are currently optional in the studio, but can be a standard of protection upon your request in the individualized sessions. If you feel sick for any reason or have been exposed to someone who has tested positive for Covid-19 in the past two weeks, please let me know so we can reschedule.

I understandI do not understand
ONLINE SERVICES We agree to use the Zoom platform for our virtual therapy sessions for convenience and/or flexibility of scheduling. We will both be connected to an electronic device (laptop, desktop, tablet, or smartphone) during the session. We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

I agreeI do not agreeNA
CANCELLATION POLICY AND FEES Payment for yoga therapy services is required at the end of each session. Twenty four hour business days’ notice is required to cancel an appointment. Failure to provide this, outside an unforeseen illness, family emergency, or any other circumstance beyond your control, will result in being billed for half the session fee.

I agreeI do not agree
CONFIDENTIALITY You have the right to confidentiality as a yoga therapy client. Information may only be released with written permission except when there are concerns about danger to yourself or others, if required by court orders, or for your insurance provider. A record is kept of services provided to you. All records are confidential and access to them will be granted to you if desired.

I understandI do not understand
By typing your name below you provide your electronic signature, and you indicate that you have read, understand, consent and have discussed this document with me and agree to the contents of this document. By signing this document, you are agreeing to begin treatment.
Name

First NameLast Name
LEGAL GUARDIANS: If you are a legal guardian for a patient, type YOUR NAME above and the NAME OF THE PATIENT FOR WHOM YOU ARE PROVIDING CONSENT below.
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First NameLast Name
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