Workshop / Group Waiver and Informed Consent Form

Welcome to Recovery Toolkit: Points and Poses for the Nervous System virtual workshop. This document contains important information about our professional services and business policies. Please read it carefully and thoroughly.

When you sign this document, it represents a contract between you, Integrated Eating Dietetics-Nutrition, PLLC and Grounded Acupuncture. 

Therapeutic Group/Workshop
Therapeutic groups vary depending on a number of factors. These include the specific needs, issues, history and personality of the client, as well as the training and personality of the clinician/practitioner. While there are many methods of treatment we may use,  this group/workshop requires an active effort on your part. Together we work to create a safe therapeutic space to become more embodied and aware of our experiences. We will be using several holistic modalities during this group/workshop including meditation, breath work, yoga therapy, aromatherapy and acupressure. The grouping of these modalities will be covered under the term "holistic modalities". 

Holistic modalities can have both benefits and risks. Because these therapeutic holistic modalities involve breath practices, mindfulness,  movement, and acupressure points you may experience uncomfortable feelings such as shame, sadness, guilt, anger, frustration, loneliness, anxiety or helplessness. On the other hand, these practices have been shown to have significant benefits for people who stay with the process. Practicing these holistic modalities can lead to a better understanding of your body and nervous system, your relationships and your life as well as an overall sense of wellness and health. However, there are no guarantees about what you will experience.

A word about eyes closed and safe set up.
Throughout the series you may hear the co-facilitators invite you to practice breath, meditation, movement and /or mindfulness exercises with your eyes closed. This is to facilitate an inner awareness. If closing your eyes does not work for you (for whatever reason) don’t do it! You can gaze down at the floor or continue to look at your screen during movement. The choice is yours! Setting up a safe space for movement is important. Please take a few moments before the practice to up your space. 

MEDICAL/LEGAL DISCLAIMER:

This series has an intention to promote health and wellbeing. The information presented is in no way intended as medical advice or to serve as a substitute for medical treatment. The information should be used in conjunction with the guidance and care of your physician and/or treatment team. Because eating disorders are a life threatening illness, It is strongly advised to consult your physician before beginning this or any program that incorporates movement, activity or exercise, especially if you have any medical condition, injury or other medical issue that contradicts physical activity. Please consult with your dietitian/nutritionist as to proper caloric adjustments needed due to this or any other type of movement or activity. In the series you may be directed to notice feelings. This is in no way intended to serve as a substitute for psychological counseling. Please consult with your psychotherapist before participating in this video.

By participating in this group/workshop series you are agreeing to accept full responsibility for your actions.

Confidentiality
In general the privacy of all communications between a client and co-facilitators (Maria Sorbara Mora and Jamie Wolfe) is protected by law, and we can only release information about our work to others with your written permission. However, there are a few exceptions: abuse or neglect. We are required by law to report suspected abuse or neglect of a child, elderly person, or disabled person.

Potential harm to self or others: If a client is demonstrating a genuine threat of inflicting serious bodily harm to another, we must take protective action such as notifying the potential victim, contacting the police, or seeking hospitalization for the client. If a client threatens to harm him or herself, we may alert appropriate individuals such as family members who can provide protection and supervision of the client and/or recommend hospitalization of the client.

Legal proceedings: In most legal proceedings you have the right to prevent us from providing any information about your treatment. However, in some cases involving child custody and those in which your emotional condition is an important issue, a judge may order me to testify.

We have found that these situations rarely occur in our practice. Should such a situation occur, we would make every effort to discuss it fully with you before taking any action.

If you use insurance to pay for this group/workshop the company will require us to provide some information about your treatment.

Informed Consent: After you have read this document and noted any questions you may have, please confirm by checking the Waiver box indicating that you have read the information in this document, we have discussed your questions and concerns, if any, and that you agree to its terms. This confirmation also means that you give your consent to treatment.

Thank you,

Integrated Eating Dietetics-Nutrition, PPLC and Grounded Acupuncture