INFORMED CONSENT AGREEMENT
RECOVER YOU 1-to-1 Program
+44 (0) 755 407 0770 | firstname.lastname@example.org | livebeyondmigraine.com
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.
RECOVER YOU is a 1-to-1 program delivered by video call. It is a 12 week program that is divided into three sections.There are eleven 1-hour, 1-to-1 video call with Jan Southern. These take place on Weeks 1-6 and Weeks 8-12.
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.
RECOVER YOU integrates techniques, such as Trigger Point Therapy, Somatic Traumatic Therapy and Mind-Body techniques with and an exploration of lifestyle and mind-set. Jan Southern develops your personal RECOVER YOU program with you over the course of the 12 weeks. Under her guidance you will learn how to confidently undertake these techniques for yourself.
By signing this Agreement, you are agreeing to undertake and practice the exercises and techniques.
Acceptance on to RECOVER YOU 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
Your eleven 1-to-1 are 60 minutes each. The date and time of your one-to-one sessions will be agreed between yourself and Jan Southern.
Your 1-to-1 sessions take place during weeks 1-6 and weeks 8-12. Week 7 is a consolidate week where you are free to spend your time as you choose. Each session takes place at the same time and on the same day each week, e.g. 10am on a Monday.
All one-to-one sessions take place face-to-face by tele-therapy via http://doxy.me/jansouthern.
This is a secure, video call system that can be accessed through computer, tablet or smartphone.
Fees and Payment
The fee for RECOVER YOU program is £3000 if paid in a single payment. The single payment fee for RECOVER YOU program is to be paid in full on acceptance into the program and signing of paperwork. Payment is via BACs, cheque or debit/credit card.
A payment plan is available. The total fee on the payment plan option is £3150.
The payment plan is three payments each of £1050. The first payment is due on acceptance on to RECOVER YOU program. The second payment is due on Week 4 of the program and the third and final payment is due on Week 8 of the program. Payment must be received for your continuation on RECOVER YOU program.
Payment is via BACs, cheque or debit/credit card.
The fee covers all eleven one-to-one sessions with Jan Southern plus instructions for the 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 RECOVER YOU
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 RECOVER YOU program. If this is not possible, you will be offered a replacement session during the next round of RECOVER YOU program.
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.
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.
Jan Southern is registered with the Information Commissioner’s Office (registration number Z3456256). A copy of her Privacy & Cookies Policy is available on her website livebeyondmigraine.com. You may request a paper copy, if you so wish.
Unless you give Jan Southern specific written consent to disclose information to other health professionals and practitioners, all client information is confidential.
Jan Southern participates in Supervision as part of her ongoing professional development. Case notes may be discussed during Supervision. At all times anonymity and confidentiality of the individual client will be maintained.
Data I Collect and Retention
Jan Southern collects personal data from you in order to deliver this service (RECOVER YOU program). Information that she collects 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 your work together. This is to meet legal requirements to HMRC and Insurers. You can 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 Jan 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 health. It has been made very clear to me that the RECOVER YOU program 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 RECOVER YOU program. 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.
Client First Name and Surname:_________________________________________