Informed Consent AgreementMigraine Reduction Practice
INFORMED CONSENT AGREEMENT
+44 (0) 755 407 0770 | email@example.com | jansouthern.co.uk
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.
Migraine Reduction Practice
Bespoke Migraine Reduction Practice is a unique 1-to-1 process. It consists of 11 individual 1-to-1 sessions. The outcomes are determined by the effort and motivation you bring to work towards a change in yourself. It is a collaborative process between you and Jan Southern. It can result in a number of benefits to you. It has the potential to help you gain new or deeper understanding of your issues and learn news ways of managing and reducing them.
On being accepted, Jan Southern will arrange an agreed time and day of the week for your eleven 1-to1 sessions.
Migraine Reduction Practice integrates body work techniques, including Trigger Point Therapy with Mind-Body techniques and an exploration of lifestyle and mind-set. Jan Southern creates your personal Migraine Reduction Practice over the course of the 10 weeks. Under her guidance you will learn how to safely, correctly and confidently undertake these techniques for yourself.
By signing this Agreement, you are agreeing to undertake and practice the exercises and techniques.
Acceptance on to Migraine Reduction Practice 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 Jan Southern does 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 your 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 Jan Southern. She may challenge some of your assumptions, habits and behaviours regarding migraine. 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, it is important to let Jan Southern know. You will work together to resolve your concerns or frustrations.
Your One-to-One Sessions
The first 10 weekly sessions are 50 minutes each. The 11th session is 1 hour. The date and time of your one-to-one sessions will be agreed between yourself and Jan Southern.
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 take place face-to-face via Jan Southern’s tele-clinic; http://doxy.me/jansouthern. This is a secure, video call system that can be accessed through computer, tablet or smartphone.
Fees and Payment
Fees for Migraine Reduction Practice are to be paid in full on acceptance into the programme and signing of paperwork. Payment is via BACs, cheque or debit/credit card.
The fee covers all eleven one-to-one sessions with Jan Southern plus 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.
Cancelling Migraine Reduction Practice
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. Where possible your replacement session will take place during the time-period of your Migraine Reduction Practice. If this is not possible, you will be offered a replacement session during the next round of Migraine Reduction Practice.
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 arrive promptly for your sessions. Arriving late will reduce the time you have to work with Jan Southern and as such could impact potential outcomes.
Contacting Jan Southern
When you leave a message on voicemail, please be sure to give your name, number and a brief message concerning the nature of your call. Jan Southern will return your call during normal work hours (Monday through Thursday) within 48 hours. These terms also apply to emails.
Please do not contact Jan Southern by text as you may miss important update information.
Data I Collect and Retention
Jan Southern collects personal data from you in order to deliver this service (Migraine Reduction Practice). 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 legal requirements to HMRC and Insurers. You can find full details on her Privacy & Cookies Policy.
Respecting your Privacy in Public
Jan Southern respects your privacy and so if you should meet in public, she will not acknowledge you unless you speak with her first. She will not ask you how you are or discuss your treatment, even if you should raise it. If she is with another person she will not acknowledge you or speak with you. (You can find more details in her Social Media Policy).
Please ask Jan Southern 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 Migraine Reduction Practice programme. I realise that the outcomes depend upon my personal investment in the 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