CHANGING MIGRAINE PILOT ONLINE GROUP PROGRAM INFORMED CONSENT AGREEMENT
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, (which includes electronic execution including, where appropriate, ‘ticking a box’ on the Website or on a document accessed via the Website) it will become an agreement between us and also provides your consent for you to participate in this Pilot Online Group Program/ and for us to begin to work together.
Pilot Online Group Program
This is a 6-week pilot/test program to assess the delivery of a new online group program created and developed by Jan Southern. It will be delivered through a private Facebook group and a weekly one hour group ZOOM interactive call.
This pilot program integrates techniques such as Somatic Traumatic Therapy techniques and Mind-Body techniques with and an exploration of lifestyle and mind-set. By signing this Agreement, you are agreeing to undertake and practice the exercises and techniques.
Acceptance on to Pilot Online Group Program is dependent on signing (which includes and return of this Informed Consent Agreement and full payment of fees.
You must be in a safe, supported situation that allows you to fully participate. This pilot program is only for people aged 18 years.
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. This pilot program is not suitable for people who are on anti-psychotic medications.
This Pilot Program is not a format nor platform for the giving, sharing nor receiving medical advice, treatment advice, medications advice etc. either formally or informally by participants.
The outcomes that you may gain from participating in this pilot program are determined by the effort and motivation you bring to work towards a change in yourself. 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.
What happens when you sign up?
You will receive a series of welcome emails sharing materials you may choose to read or watch prior to the Pilot Program commencing. The first email you will receive will allow you to choose the time and date of your ZOOM constructive feedback call will with Jan Southern to share your experience of the Pilot Online Group Program. You can, of course, choose to unsubscribe from these emails at anytime.
You will be invited by emails to join the private Facebook Group 5 days before the Pilot Online Group Program begins. Only the people in the group, Jan Southern and her support team will be able to see who is a member.
During the Pilot Online Group Program you will receive handy emails letting you know about what is happening that week. You may choose to unsubscribe from these emails at any time.
It is a place to access materials shared by Jan Southern, interact with Jan Southern and other members of the Pilot Group. It is the place for you to share your thoughts, questions, progress and celebrate your practice.
The Facebook Group will be open from 8am on the first Monday of the starting week of the pilot program. From 5pm on the final Friday of the pilot program, the Facebook Group will be closed to further posts and/or comments, but you will be able to view materials posted by Jan Southern until 5pm on the following Sunday. After this date the private Facebook Group will be closed to all participants.
By signing this agreement you are agreeing to abide by the rules of the Facebook Group as set out by Jan Southern. These include:
1) The private Facebook Group is not a forum for participants sharing medical advice, medications advice nor treatment advice either formally or informally. Any such materials will be deleted by Jan Southern or a member of her support team when they become aware of such material. The person involved will be notified by email to refrain. Should the individual comment/post such material a second time they will be removed from the Group and their participation in this Pilot Online Group Program will be cancelled. No admin fees will be returned and the participant will not receive the bonus thank you gift. < /p>
2) No sharing, downloading or copying of any materials either supplied in written, audio or video format that are uploaded to the private Facebook Group unless authorised by Jan Southern. All materials in this Pilot Online Group Program are not your personal use and are not to be shared or copied out with the private Facebook group.
3) No posting by participants of third party materials in any format. Any third party materials will be deleted. The person posting will be sent a reminder by email not to do so again. If that person breaks this rule a second time they will be removed from the Group. No admin fees will be returned, their participation in the Pilot Online Group Program will be cancelled and they will receive the bonus thank you gift.
Jan Southern may choose to post and share with the Group carefully selected outside articles, videos and other materials to support you in the Pilot Online Group Program.
4) No marketing or posting by any participant of their own therapy/treatment practice. Any such post will be deleted and the individual will be removed from the Group. No admin fees will be returned, their participation in the Pilot Online Group Program will be cancelled and they will receive the bonus thank you gift.
5) Any offensive and/or bullying comments will be removed and the person responsible will be removed from the private Facebook Group. Their participation in the Pilot Online Group Program will be cancelled.
6) The private Facebook Group will be a supportive place where we are all known to each other. Although you are all in the group together and you will be interacting within the group, it is still important to respect people’s personal privacy and space and not to send personal DMs to anyone group participant, Jan Southern and/or her support team.
7) Other rules that may be posted by Jan Southern during the Pilot Online Group Program.
ZOOM Group Calls
A one-hour weekly interactive group ZOOM call will be held. You will receive an invitation link to the ZOOM call either via email or in the private Facebook Group. The ZOOM calls will be recorded. The recording will be shared in the private Facebook Group. If you are unable to attend the weekly call you can post any questions you may have prior to the call and watch the video afterwards.
Payment for your participation in the Pilot Online Group Program is made up of:
1) Your active engagement with the program and private Facebook Group.
2) One 15 minute feedback video call with Jan Southern on the completion of the Pilot Program. This call is for you to share your constructive feedback of your experience of and participation in the Pilot Program. The date and time of this to be agreed in advance of the start of the program between yourself and Jan Southern. This call will be ZOOM and will be recorded for data collection purposes only. It will not be shared with anyone other than Jan Southern. If you should be unwell on the schedule date for this call, it will be rearranged for a later date.
3) Testimonial. If you believe/consider/have had a positive and supportive experience of the Pilot Program you agree to providing Jan Southern with a testimonial for her to use for marketing purposes in the format and of the platform of her choosing.
The format of your testimonial is your choice. You may choose to provide a written testimonial or video testimonial. If written you may choose either to provide or not provide a photograph. You may choose whether you wish your testimonial to be anonymous, first name, initials only or your full name.
4) £39 administration fee payable prior to the start of the Pilot Program. This fee does not cover Jan Southern’s time nor the resources provided. It is a contribution towards admin and technical support costs.
5) Complete a short online survey up to 4 weeks after the close of the Pilot Online Group Program.
All materials are copyrighted by Jan Southern. Downloading of videos and other materials unless authorised by Jan Southern is not allowed. During the Pilot Online Group Program Jan Southern will make available certain materials that you may down and keep. These are for you own use and must not be shared publicly or used for commercial purposes.
Bonus Thank You Gift – Lifetime Access to Materials*
This is a Pilot Online Group Program. If this Program goes ahead and is offered to the wider public, you will receive life time access to the resource materials chosen by Jan Southern via the platform chosen by Jan Southern in the format of her choosing.
This bonus thank you gift excludes free participation in future private Facebook Groups associated with each new cohort.
Lifetime access to the publicly-offered Online Group Program (as defined below) will be given only on fulfilment of your payment agreement as outlined above in Payment.
You will have lifetime access to the materials that Jan Southern gives you permission to download (videos will not be made available for downloading) during the Pilot Online Group Program
*Lifetime access, refers to the life of the program that Jan Southern chooses to continue to offer the program.
For Your Personal Use Only
Participating does not allow you to use the material and learning you gain to teach, treat or train other individuals. The materials and learning you gain are for your own personal use.
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 commenced participation in this Pilot Online Course Program Jan Southern reserves the right to withhold up to 10% of your admin fee.
The admin fee is non-refundable for cancellations made after this 14-day cooling off period.
Prior to the start of the Pilot program, please contact Jan Southern via firstname.lastname@example.org. Jan or a member of her team will answer within 48 hours Monday through Thursday. Once the Pilot Program has begun, please post questions regarding the Program to Jan Southern within the Facebook Group following the instructions given in the private Facebook Group.
You may request a paper copy, if you so wish.
Jan Southern participates in Supervision as part of her ongoing professional development. 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 (Pilot Online Course Program). Information that she collects includes your full name, date of birth, contact details including physical address. 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.
Please ask Jan Southern to address any questions or concerns that you have about the information in this Informed Consent Agreement before signing that you have read and agreed to its terms.
It has been made very clear to me that the Pilot Online Group Program I agree to participate in 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 confirm that I am in a space and place where I can fully participate in this Pilot Online Group Program.
I understand that the purpose of this Pilot Online Group Program is to test and assess the program, its delivery and you experience as a participant.
I acknowledge that it is my choice to participate in the Pilot Online Group 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.