Informed Consent Agreement1-to-1 programme with Jan Southern
INFORMED CONSENT AGREEMENT
Welcome to my practice
This document contains important information about my professional services and business policies and how they may affect you. Please read it carefully and make note of any questions you want to discuss with me. Once you sign this document, it will become an agreement between us and also provides your consent for us to begin to work together.
Take Control of Your Migraine 1-to-1 Programme
Take Control of your Migraine programme is a unique 1-to-1 process, consisting of 11 individual sessions, with the outcome determined by the effort and motivation you bring to work towards a change in yourself. It is a collaborative process between you and me. It can result in a number of benefits to you and has the potential to help you gain new or deeper understanding of your issues and learn news ways of managing and solving them.
On being accepted on to the programme, Jan Southern will arrange an agreed time and day of the week for your eleven 1-to1 sessions. The first 10 sessions take place once a week over ten weeks. Each session takes place at the same time and on the same day each week, e.g. 10am on a Monday. The 11th session takes place one month after the 10th session, at an agreed time and date.
All one-to-one sessions can take place either in person at Jan Southern’s Edinburgh studio or via her virtual clinic; http://doxy.me/jansouthern. The programme integrates body work techniques, including Trigger Point Therapy with mind-body exercises and exploration of lifestyle and mindset.
Unlike other therapy approaches that you leave dependent on the practitioner, Jan Southern teaches you how to safely, correctly and confidently undertake these techniques for yourself. This is an essential part of the programme; instead of receiving hands-on treatment from Jan Southern, you will learn and gain vital new skills under her expert guidance and tuition.
By signing this Agreement, you are agreeing to undertake and practice the exercises and techniques shared in your preparation techniques and your one-to-one sessions.
Acceptance on to the Take Control of Your Migraine programme is dependent on successfully being selected to participate, the signing and return of this Informed Consent Agreement and full payment of fees.
It is important to say here also what it is not. It is not counselling nor is it a replacement for counselling. It is not a replacement for medical advice or treatment from your GP and/or consultant. Please note that I do not diagnose illnesses, diseases nor any other physical or mental disorders or conditions. It is recommended that you consult with your doctor about any symptoms that may require diagnosis or medical attention and before adjusting any medication or course of treatment. Jan Southern must be made aware of any existing medical conditions before our first session and be kept informed of any updates or changes during the course of our relationship.
Though there are no guaranteed results, the approach works best when you are honest with yourself and with me. I may challenge some of your assumptions, habits and behaviours regarding the role you play in your recovery and moving forward. It’s not a linear process; sometimes the work can feel quick and painless; other times it may feel like you’ve reached a plateau or even slipped backwards. This is normal. If you are ever feeling stuck, please let me know, and we can work together to resolve your concerns or frustrations.
Your One-to-One Sessions
Your first and final 1-to-1 sessions are for 60 minutes each. Sessions 2 through 10 last for 50 minutes each. The date and time of your one-to-one sessions will be agreed between yourself and Jan Southern.
These sessions will occur one time per week, at the same time and day. The exception to this are pre-booked holidays either your own or those of Jan Southern. You will make Jan Southern aware of any such pre-booked holidays when accepted on to the Take Control of your Migraine Programme. Jan Southern will likewise inform you of any such pre-booked holidays.
Fees and Payment
Fees for this 1-to-1 programme can be paid in a single payment or in three instalments. Single payment is made in full on acceptance onto the programme and on signing of paperwork.
The three instalments option is as follows: 1st instalment on acceptance onto the programme and signing of paperwork, 2nd instalment prior to Session 4, 3rd instalment prior to session 6. Payments must be received for continuation in the programme.
Payment is via BACs, cheque or debit/credit card.
The fee covers all eleven one-to-one sessions with Jan Southern and instructions for techniques and methods that you agree to undertake on signing this Informed Consent Form.
Extended session and telephone conversations exceeding ten minutes will be charged an additional fee. You will be notified of such additional fees prior to any such extended sessions or telephone conversations taking place.
Cancellation of the Take Control of Your Migraine Programme
You have a 14-day cooling off period, from signing this Informed Consent Agreement, in which you may cancel this agreement. If you cancel within this 14-day cooling off period you will receive a full refund of your fees.
Exception: If during this 14-day cooling off period you have received your one-to-one Foundation session Jan Southern reserves the right to withhold up to 10% of your fees.
All fees are non-refundable for cancellations made after this 14-day cooling off period.
Rescheduling due to Illness
If due to illness you are unable to attend one of eleven one-to-one sessions, you must inform Jan Southern immediately. Jan Southern will endeavour to offer you a replacement session. However, this may have to take place at a different time and day to your agreed one-to-one sessions.
In the event that Jan Southern has to cancel your pre-arranged one-to-one session she will offer you a replacement session. Please note this may have to take place at a different time and day to your agreed one-to-one sessions.
It is your responsibility to let me know if you are running late to our sessions. If you arrive 15 minutes or more late for your session it will be forfeited.
When you leave a message on my voicemail, please be sure to give your name, number and a brief message concerning the nature of your call. I will return your call during normal work hours (Monday through Thursday) within 48 hours. These terms also apply to emails.
Please do not contact me by text as you may miss important update information.
Data I Collect and Data Retention
I collect personal data from you in order to deliver this service (1-to-1 programme). Information that I collect includes your full name, date of birth contact details, GP contact details and health & wellbeing information. This information is stored securely and is retain for 7 years following the completion of our work together. This is to meet my legal requirements to HMRC and my Insurers. Please refer to my Privacy & Cookies Policy further information.
Respecting your Privacy in Public
I respect your privacy and so if we should meet in public, I will not acknowledge you unless you speak with me first. I will not ask you how you are or discuss your treatment, even if you should raise it. If I am with another person I will not acknowledge you or speak with you. (You can find more details in my Social Media Policy).
Please ask me to address any questions or concerns that you have about the information in this Informed Consent Agreement before you sign.
I confirm that I have disclosed all my known medical conditions and agree to keep Jan Southern updated on my physical health. It has been made very clear to me that the therapy I agree to receive is not medicine or a substitute for medical examination, diagnosis, or treatment, and it has been recommended that I consult my doctor about any medical condition I might have.
I acknowledge that it is my choice to participate in Take Control of your Migraine programme. I realise that the outcome of therapy depends upon my personal investment in the therapy process. I have familiarised myself with the fees and charges for the services provided by Jan Southern. I acknowledge responsibility for payment of these charges
I acknowledge that I have received, read and understood the information in this Informed Consent Agreement and in the accompanying ‘My Social Media Policy’ fully and completely and have discussed any questions I had about the information.
Client First Name and Surname:_________________________________________
Date______________________________________Informed Consent Agreement