Winterspring Sanctuary
Client Informed Consent Form
Welcome to the Winterspring Sanctuary equine-assisted mental health and wellness program. We are looking forward to supporting you on your personal journey of healing, recovery and personal growth. WinterSpring is offered by Jenny Shroyer, LCSW or Sara Ansell, LPC who co-facilitates individual and group sessions with Eagala-certified equine specialist Nicole Will.
Confidentiality and Circle of Care
We respect the privacy of our clients, hold in strict confidence all information about clients and comply with applicable privacy and other legislation. No information will be released to a third party without your prior written authorization. At any time, you have the right to withhold wor withdraw consent to, or place conditions on, the disclosure of your information. Exceptions to confidentiality include the legal and/or ethical obligations to:
1. Inform a potential victim of a client’s intention to harm them;
2. Inform an appropriate family member, health care professional, or police if necessary of a client’s intention to end his or her life;
3. Release a client’s file if there is a court order to do so;
4. Inform the Children & Youth Services if there is suspicion of a child at risk of harm or in need of protection due to neglect, or physical, sexual or emotional abuse;
5. Report sexual abuse of a client;
6. Report elder abuse of a resident in long-term care;
While these events are rare, we would like to help you become aware that these possibilities do exist. Our overall goal is to provide an environment in which you feel comfortable to share personal concerns in confidence. Other instances to be aware of include the following:
Winterspring may share pertinent anonymous and/or de-identified information about sessions within the confidential context of case consultation with other professionals, for the purposes of ensuring quality care or completing the consultation requirements of different professional bodies.
All team members, such as co-facilitators, horse handlers or volunteers (as can be the case in group workshops or retreats) may become privy to private information about you as a result of their involvement in programs you are attending as a participant. All team members have signed confidentiality agreements and have a duty to protect your private information as well.
Sessions take place at a boarding facility. While the farm is generally quiet on weekdays, there may be other people on the property doing other horse-related activities.
Should the team need to cancel or reschedule, you may be contacted by a representative who is acting on the team’s behalf, such as an office manager. This representative will be obliged to ensure confidentiality.
Ethics
Winterspring Sanctuary abides by the standards and ethics of reputable professional bodies, and aims to conduct the therapeutic plan with professionalism, transparency and accountability while fostering relationships that are open, authentic and approachable. We respect the Code of Ethics of Eagala (www.eagala.org).
Should you have any questions or concerns, please feel free to:
1. Contact Jenny Shroyer, Sara Ansell or Nicole Will directly at winterspringsanctuary@gmail.com;
2. Contact the Bureau of Professional and Occupational Affairs;
3. Contact the Eagala Ethics Committee.
The outcome of your time with the horses is difficult to predict or guarantee, since it is dependent on a number of factors, such as the fit between you and the co-facilitation team, current adverse conditions that are actively contributing to your symptoms, and your readiness and willingness to work towards set goals. However, the Winterspring treatment team will do their best to help you to handle the risks safely and experience at least some of the benefits.
Privacy and Record Keeping
Records are retained for at least 10 years from the date of the last interaction with the client, or for 10 years from the client’s 18th birthday, whichever is later. All information is maintained in compliance with the The Health Insurance Portability and Accountability Act (HIPAA). This means that all personal information obtained, used, and disclosed in therapy sessions is done so with your consent. Your personal information is protected by specific safeguards including locked cabinets and computer passwords. You may request a copy of your records for a reasonable fee for the time spent preparing, copying and mailing the file (where applicable).
Cancellation Policy
To cancel your session, please contact Nicole Will at 917.808.6367 (cell), or by email at winterspringsanctuary@gmail.com at least 48 hours prior to your scheduled appointment.
Cancellations within 48 hours from the session and missed sessions will be billed at the full rate. If it is possible to reschedule within the same week, the cancellation fee will be waived. Every attempt will be made to reschedule in emergency situations, but sometimes there are no other available times within the same week.
If you cancel or miss 3 consecutive appointments, or fail to respond to attempts at contacting you, we reserve the right to discontinue your treatment and you will be provided with information about other services that might be of assistance if this is of interest to you.
Fees for missed or cancelled sessions are not usually covered by extended health benefits plans.
EXCEPTIONS: Cancellation or missed session fees will be waived on compassionate grounds, for example: in the event of sickness, a medical emergency requiring urgent professional treatment, or death in the family.
If finances or payment of sessions becomes an issue, or your life circumstances change, please contact Nicole to explore options in terms of repayment plans or additional services or resources to support you in your healing.
CONNECTIVITY ISSUES: Farms are located in rural areas that may have weak cell phone and Internet reception. Messages may sometimes not be delivered until we are back in range. If you are not familiar with the farm location, please review Google Maps or GPS ahead of time and contact us for directions if necessary. Please refer to the Client Instructions sheet for address and contact info.
Informed consent for equine-assisted trauma recovery is essential and out of respect for your right of choice and self-determination. Consent must be given voluntarily, knowingly and intelligently. You have the right to change your mind and withdraw informed consent at any time, terminate treatment, or refuse a particular treatment modality if you are not comfortable with it.
I have read and fully understand the information contained in this document. I understand that psychotherapy, personal growth interventions and equine-facilitated therapy are not an exact science and acknowledge that no guarantees have been or can be made to me about the outcomes of these programs/services. I understand that the therapy team includes both a licensed therapist and an equine specialist in addition to horse(s). Any and all questions I have regarding the contents of this document have been answered to my satisfaction and I would like to participate in the program.