By attending this class, you (attendee) agree to the following terms:
LIMBIC REGULATION PROGRAM CONSENT
This document is intended to provide important information to you regarding your treatment. It is your right to have a complete explanation for any questions you may have, now or in the future.
About Your Provider
Casey Kania BSN, MSSW is an Integrative Limbic Coach with a focus in PANS/PANDAS and OCD. Casey holds a bachelor's degree in nursing from Belmont University, a master's degree in social work from the University of Tennessee and is a Certified Safe and Sound Protocol Provider. She has worked in a variety of community mental health settings prior to joining Sanctuary Functional Medicine including inpatient and outpatient facilities.
Purpose of the ReBalance Program
The purpose of this class is to support individuals in learning and applying techniques designed to retrain and regulate the limbic system. This program includes education, movement, breathwork, visualization, and other self-directed neuroplasticity tools. It is intended as a complement to—not a substitute for—medical or psychological care.
ReBalance Program
This program consists of 6, one hour long sessions that will run over a course of 3 months. If you cannot attend sessions in person a livestream link will be sent to you. If you are unable to attend via in person or live stream, a recording of the session will be sent to you within 24 hours of the scheduled class.
Participation
Participation in the class I entirely voluntary and educational in nature. It does not constitute medical, psychological, or psychiatric treatment. I agree to consult my healthcare provider regarding any medical or psychological concerns I may have.
I understand that limbic training may bring up emotional discomfort, I will let the facilitator know if I have any previous medical or mental health conditions that may be exacerbated during this process. I assume full responsibility for my own wellbeing and participation, and I will notify the facilitator if I feel overwhelmed or need support during the class.
Confidentiality
I agree to respect the confidentiality of other participants and will not share personal information disclosed during the session outside of the group. I understand the facilitators will treat personal disclosures with respect and discretion, though complete confidentiality cannot be guaranteed in a group setting.
I agree to not share, teach or distribute any of the ReBalance Program information or materials.
BILLING AND PAYMENT
Insurance
We do not currently accept insurance as a form of payment. We do not provide medical coding or super bills.
By signing these policies and procedures you are waving your right to have any provider and/or medical record at Sanctuary Functional Medicine subpoenaed.
Electronic Communication
You are welcome to contact your Provider via a secure message in your patient portal. I will typically be able to return your message within 48 hours Tuesday - Thursday.
Emergencies
Due to the limited, outpatient nature of Sanctuary Functional Medicine, we do not act as an emergency contact. In case of an emergency please refer to your safety plan if you are in a crisis and feeling suicidal, overwhelmed, or unsafe. Please call the crisis line or go to your nearest emergency room in these instances.
If you need immediate help, you may obtain assistance by calling:
24/7 TN Statewide Crisis Phone Line at 855-CRISIS (855)-274-7471
Sexual Assault Center 24/7 Crisis and Support Line at (800) 879-1999
911 or go to your local hospital emergency room.
If there is an emergency where your provider becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, they will do whatever they can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, they may also contact the person whose name you have provided on the safety plan.
DUAL RELATIONSHIPS AND SOCIAL MEDIA
For the efficacy of our work together, it is important that we maintain appropriate boundaries. Your provider cannot enter a personal relationship with you. This boundary must be maintained even after our working relationship is terminated.
If you see your provider outside of the office, they will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize that. However, if you acknowledge them first, they will be more than happy to speak briefly with you, with respect, as to not engage in any lengthy discussions in public or outside of the therapy office.
Due to the importance of your confidentiality and the importance of minimizing dual relationships, SFM providers do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). We believe adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our working relationship.
MINORS
If you are a minor, your parents may be legally entitled to some information about your sessions. Your provider will discuss with you and your parents' what information is appropriate for them to receive, and which issues are more appropriately kept confidential.
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This class is open to the public, so if the attendee is also a patient of Sanctuary Functional Medicine, patient status will be kept confidential by the instructor and staff.
By registering, you agree to receive event-related resources to your email from Sanctuary Functional Medicine. These emails will not contain personal health information and are for educational purposes only.
Sanctuary Functional Medicine, 4085 Mallory Ln, Suite #200, Franklin, TN 37067, Phone: 615-721-2001