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Informed Consent

INFORMED CONSENT FOR
ENERGY MEDICINE PRACTITIONERS

 

Introduction

 

Obtaining “informed consent” is one of the most fundamental procedures for protecting a client’s rights. Informed consent means that prior to establishing a professional relationship, the prospective client has been provided with enough information to make a reasonable determination about whether to enlist the services you offer. This information includes the goals of your services, the procedures, your qualifications; warnings about possible side effects; information about fees, length and frequency of sessions, the likely duration of the professional relationship, and alternative services that might be sought for reaching the same goals. The differences between your services and the services provided by a licensed health care professional should be made particularly explicit. Essential for informed consent are that the client be able to understand this information and be able to freely choose whether to proceed with the services. Having the client sign a statement early in (or prior to) the first session is one of the most basic ways that informed consent can be responsibly obtained.

 

The following Informed Consent Statement may be used as a rough model as you develop your own. Because state laws differ in what may be practiced without a license and the language that may be used, and your Informed Consent Statement may be your first formal communication with your client, you will want to personalize it as appropriate and be sure it is consistent with pertinent laws and regulations. In addition to providing information that helps the client understand your services, the following sample aims to establish a legally enforceable business relationship with the client. Doing this well minimizes the risk of the misunderstandings that might become the basis for ethical complaints or malpractice suits.  This form uses the language for Certified Eden Energy Medicine practitioners, but can easily be adapted for Reiki, Healing Touch, or other certified energy healing professionals. A separate form for Energy Enhancement Coaches is also available.

 

The following includes some general language about risks and benefits, but because these may vary considerably, the risk and benefits should be supplemented orally or in writing by the practitioners. No single document is appropriate for all situations. For example, it is probably important to have a more thorough discussion of risks and benefits with clients who are seeking your help and who also have a serious medical condition. The goal is to have no misunderstandings about the limitations, as well as the scope of the services you offer. Steps that should be followed if the condition worsens can then be considered. An informed consent agreement is only the beginning of providing informed consent. Important issues contained in the agreement, or not contained in it, should be discussed when it is anticipated that they are likely to occur, particularly if the client is likely to feel betrayed or feel angry when they do, such as in instances where you are required to disclose confidential information. You may orally provide whatever additional information is necessary and make a note in the client’s record about what was said.

 

Laws relating to client access to personal records, confidentiality, and testimonial privilege differ from state to state and profession to profession. In the spirit of informed consent, please be informed that you are strongly advised to have an attorney who knows the specific laws in your state and for your specialty review a draft of the consent form you plan to utilize. Also take care that your final version does not include language that could be interpreted as a guarantee or implied warranty regarding the services rendered.

 

Feel free to adapt the following draft for your practice or setting. It builds upon an earlier sample Informed Consent Statement for energy practitioners provided by Douglas J. Moore, Ph.D., as well as two other informed consent statements graciously provided by Laura S. Brown, Ph.D., ABPP, and by Bruce E. Bennett, Ph.D., and Eric Harris, J.D., Ed.D.

 

DISCLAIMER: This document is not necessarily appropriate in all aspects for your situation nor is it a substitute for legal consultation.[[YOUR LETTERHEAD]]

 

  1. ENERGY MEDICINE SERVICES
  2. DISCLOSURE STATEMENT AND AGREEMENT

 

Welcome! This document contains important information about my professional services and business policies. It is rather long because it covers a wide range of possible situations, many of which will not apply to you. Still, it provides a framework for understanding the services you are considering. Please read it carefully and note any questions you might have. We can discuss them at our next meeting. If you decide to use my services and sign this document, it will represent an agreement between us.

 

  1. WHAT IS ENERGY MEDICINE?

 

I am a certified practitioner of Eden Energy Medicine. Energy Medicine is an approach that involves balancing and restoring your body’s natural energies for the purposes of increasing your vitality, strengthening your mental capacities, and optimizing your health. The form I use draws from Donna Eden and her book, Energy Medicine.

 

Roots.  The techniques you will be experiencing and learning trace back to ancient healing and spiritual traditions such as yoga, tai chi, and acupuncture. The form I use and teach is thoroughly modern and does not require adherence to any particular set of beliefs or practices. The core concept is that your personal well-being and effectiveness are directly related to the state of your body’s energies.

 

Your Body’s Energies.  Einstein’s famous formula, E=mc2, changed the course of physics and of history by showing that matter is a form of energy. Our bodies are comprised of molecules that are in constant motion and that are continually being influenced by outside forces. The medical profession utilizes electromagnetic fields with devices such as EKGs, EEGs, and MRIs. The vital role these energies play in our everyday health and well-being is well established. Scientists from a range of disciplines are now introducing concepts such as “force fields” and “subtle energies” to explain a range of empirical observations. Subtle energies are called “subtle” because they are not easily detectable and scientists have not been able to develop instruments to reliably measure them. Nonetheless, people throughout history and across cultures have described seeing or feeling subtle energies.

 

Enhancing Your Body’s Energies.  You may have heard about subtle energy through terms such as the “life force,” “chi,” “meridians,” “chakras,” “biofields,” or “auras.” In many healing traditions, the “life force,” the animating power whose presence defines life and whose absence defines death, is understood as a form of subtle energy. Eastern cultures in particular have studied such energies for millennia and have successfully applied their understanding for enhancing both physical and emotional health. Systems designed to influence the body’s subtle energies include yoga, Reiki, acupuncture, acupressure, tai chi, therapeutic touch, and energy medicine, to name just a few. Many hospitals in the United States now include such methods to help with the healing of a variety of conditions.

 

Energy Medicine Techniques.  The techniques I will be using and teaching you are based on the premise that by promoting balance and flow in the body’s electromagnetic and subtle energies, health and well-being are enhanced. The techniques may involve the use of certain postures or movements or touching, holding, pressing upon, tracing, or circling over specified areas of the skin. They move, balance, enhance, and restore the body’s energies. I may also employ a procedure called “energy testing” where I apply light pressure to your outstretched arm, sometimes while you or I touch another area of your body. This is a way of assessing how your energies are flowing through specific areas of your body and may help us identify the techniques that will be most beneficial for you. The methods we will be using lend themselves to highly individualized applications in the office as well as to back-home self-care.

 

  1. WHAT ARE THE LIMITATIONS
    OF MY ENERGY MEDICINE PRACTICE?

 

Although Energy Medicine uses the term “medicine,” it does not imply that Energy Medicine practitioners are practicing medicine. Energy Medicine is a term used by many training programs that teach people how to assess and correct for energy imbalances in the body. Energy Medicine is not a substitute for the diagnosis and/or treatment of medical or mental health conditions by a licensed health care professional. If you have a disorder that has been diagnosed by a licensed medical or mental health professional or a condition that should be evaluated by a licensed health professional, my services should be used only in conjunction with your obtaining that care. I do not diagnose or treat medical or mental health disorders, nor am I trained or licensed to do so. Energy Medicine attempts to optimize the body’s overall health and vitality, but it is not to be used instead of appropriate care from a licensed professional.

 

Besides the fact that Energy Medicine does not diagnose or treat illness, another difference between my services and visits to a medical doctor is that effective energy work requires your active involvement between sessions. Our sessions will establish energy patterns that optimize body, mind, and spirit. Reinforcing these new patterns through the practice of energy exercises at home will reinforce, maintain, and extend the benefits you receive in the sessions.

 

Energy Medicine techniques bring disturbed energies back to a state of balance and harmony. These corrections will generally consist of various forms of light or deeper touch and of movement of my hands within your body’s energy field. If you are uncomfortable with being touched or with any of the procedures being used, please tell me immediately and I will instantly stop.

 

While the methods I use and teach are gentle and considered non-invasive, it is possible that physical or emotional after-effects may occur after your energies have been stimulated and adjusted. In some instances, deeper pressure is used to move energies that may be blocked or congested in a particular area of the body, and this may cause some pain or discomfort. Dizziness, nausea, or anxiety are relatively unusual but not unheard of side-effects to energy work. If any procedure is uncomfortable or leads to discomfort, please tell me at once. I will instantly stop if you request me to do so and can often provide a technique to counter the discomfort.

 

MY BACKGROUND AND TRAINING

 

[[Include degrees, certificates, licenses, institutions, specialties, philosophy, etc.]]

 

MEETINGS

 

I generally schedule one appointment of 90-minutes’ duration per week, at a time we agree upon. Sessions may also, by prior agreement, be longer, shorter, more frequent, or less frequent.

 

PROFESSIONAL RECORDS

 

I keep brief records on each session, primarily noting the date of the session, the interventions used, and progress or obstacles observed as they relate to your goals in working with me. You are welcome to request, in writing, that I make available to other health care providers a copy of your file. I maintain your records in a secure location that cannot be accessed by anyone else. I will maintain your records for at least five years after our last contact, after which time I may securely dispose of them.

 

CONFIDENTIALITY

 

[[Some provisions will vary on a state-by-state basis]]

 

With the exception of special situations described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. Under the provisions of the Health Care Information Act of 1992, I may under certain circumstances legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy to the best of my ability. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a session with you.

 

You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically (for example, sending bills to your insurance company), it will be done with special safeguards such as a secure server to insure confidentiality. If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my Internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrators of the Internet service provider. Any email I receive from you, and any responses that I send to you, will be kept as a part of your treatment record. Following are seven exceptions to your right to confidentiality:

 

1. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state or local agency.

 

2. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.

 

3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and contact the police, a local crisis team, or a family member or other intimates.

 

4. If you tell me of the behavior of another named health or mental health care provider which suggests that this person has either (1) engaged in sexual contact with a patient, including yourself, or (2) is impaired from practice in some manner due to cognitive, emotional, behavioral, or health problems, then the law requires me [[this particularly varies by state]] to report this to the practitioner’s state licensing board. I would inform you before taking this step. If you are my client and also a health care provider, however, your confidentiality remains protected under the law from this kind of reporting.

 

5. In certain legal proceedings, particularly those involving child custody or those in which your emotional condition or treatment is an important issue, a judge may order my testimony. Confidentiality is not protected when a judge makes such an order or in certain other legal procedures. Consult with an attorney if you are involved in a legal situation where such confidentialities may be at issue.

 

6. If am asked to provide services to your spouse, partner, or another member of your family, we will in advance establish the limits of confidentiality. It generally confines a practitioner’s effectiveness when required to keep secrets, so my policy in most circumstances is that what you say and what we do can be shared with other family members I am working with. If this is what we establish, do not tell me anything you wish kept secret from other intimates who are receiving sessions from me.  If confidential information is a concern, it may be better for each family member to work with a different practitioner.

 

7. I may occasionally find it helpful to consult other professionals about a client. During a consultation, I make every effort to avoid revealing the identity of the client. The consultant is also bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.

 

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, please discuss with me any questions or concerns that you may have. I will be happy to explore these issues with you, but formal legal advice may be needed from an attorney because the laws governing confidentiality can be quite complex.

 

MINORS

 

If you are under eighteen years of age, please be aware that the law may provide your parents or legal guardians the right to examine my records of our work together. It is my policy to request a written agreement from parents to waive their right to access your records. If they agree, I will provide them only with general information about our work together unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have about what I am planning to discuss. [[The laws on providing health care services to minors without parental consent vary from state to state—be sure your wording is consistent with the local regulations.]]

 

PROFESSIONAL FEES

 

My fee for a 90-minute session is $XXX. If we decide to meet for a longer session or a shorter session, I will bill you prorated on this hourly fee. In addition to scheduled appointments, I also pro-rate the hourly fee for other professional services you may request. Other services might include emergency telephone conversations lasting longer than 10 minutes, listening to lengthy voice mail messages, reading and responding to e-mails other than for routine business, attendance at meetings with other professionals you have authorized, and the preparation of requested records or treatment summaries. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $XXX per hour for preparation and attendance at any legal proceeding.

 

BILLING AND PAYMENTS

 

You will be expected to pay for each session at the time it is held unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested.

 

Once an appointment is scheduled, you will be expected to pay for it unless you provide 24-hours' advance notice of cancellation. If you are late, we will still end on time and not run over into the next person's session. If you miss a session without canceling, or cancel with less than twenty-four hours' notice, you must pay for that session by the time of our next meeting unless we both agree that you were unable to attend due to circumstances beyond your control. In circumstances of unusual financial hardship, I may be willing to negotiate a payment installment plan.

 

If that is done and your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information released is the client’s name, contact information, dates and type of services provided, and the amount due.

 

CONTACTING ME

 

I am often with a client or otherwise not immediately available by telephone. When I am unavailable, you will reach my voice mail. I monitor it frequently and will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If it will be difficult to reach you, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or, if you are experiencing a medical emergency, call 911 or go to the emergency room of a nearby hospital.

 

OTHER ASPECTS OF OUR RELATIONSHIP

 

I Welcome Your Questions.  You have the right to ask me questions about anything that happens in our work together. I'm always willing to discuss how and why I've decided to do what I'm doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns and can request that I refer you to someone else if you decide I'm not the right practitioner for you. You are free to terminate our work together at any time.

 

Contacts Outside Our Work Together.  I generally avoid social and business relationships with my clients. Our work together will be most effective when kept free from possible outside entanglements. I, of course, never engage in sexual intimacies with clients.

 

Touch.  Physical contact, even in a healing relationship, can be a sensitive matter because touch can be easily misinterpreted and feel too intimate, uncomfortable, or sexual in nature. Touching in a sexual manner is unethical within a professional healing relationship, illegal, and will never be a part of your treatment. Many of the methods I will use, however, are likely to involve touch. The theory behind such methods is that touching or holding points can assist me and you in identifying and shifting imbalances in your energies. At such times, you would remain fully clothed, with perhaps the exception of your shoes. I would always explain ahead of time where I would touch, and you can let me know if you are comfortable with it or not. I will always honor any requests not to touch.

 

Touch can also be a potential problem in a healing relationship if you have had a history of paranoia, have been diagnosed with borderline personality disorder, have been sexually or physically abused, have suffered from other types of trauma, or if you tend to dissociate or detach from your sense of self. Please let me know if you fall into any of these categories prior to our starting our work together. We can discuss any emotional risks associated with touch that may be of concern to you. Furthermore, if you have any misgivings, doubts, or any negative reactions to any physical contact, it is very important that you let me know as soon as possible so that we can discuss your concerns. If you are uncomfortable talking to me, I encourage you to talk through such concerns with another professional. If you wish, I can make a referral for you.

 

Legal Proceedings.  If you are involved in legal proceedings based on your having been traumatized, please understand that the goals of our work together may involve healing the physical and emotional aftermath of the trauma, and this could adversely affect your ability to provide legal testimony that carries the same impact as it would prior to treatment.

 

Terminating Treatment.  You normally will be the one who decides when our work together will end, but there are three exceptions to this. If I determine that I am unable, for any reason, to provide you with the services you are requesting at a high professional standard, I will inform you of this decision and refer you to another practitioner who may better meet your needs. Second, if you verbally or physically threaten or harass me, my office, or my family, I reserve the right to terminate you from treatment immediately and unilaterally. Third, I reserve the right to refuse or terminate a session if you or anyone in the session is suspected of being under the influence of a mood-altering substance. You will be responsible and charged for full payment of the normal fee.

 

Vacations.  I am away from the office several times each year for vacations or to attend professional meetings. I will make every effort to tell you well in advance of any anticipated lengthy absences and to discuss other options for continuing to work toward your goals during my absence.

 

COMPLAINTS

 

If you are unhappy with the way our work together is proceeding, I hope you will talk about it with me so that I can respond to your concerns directly. I will take such concerns seriously and meet them with care and respect. You are also free to discuss any complaints about me with anyone you wish. You do not have any responsibility to maintain confidentiality about what I say or do. You are the person who has the right to decide what you want kept confidential. If you believe that I have been unwilling to listen and respond, or that I have behaved unethically, you can register a complaint about my behavior with the organization that certifies me as an Eden Energy Medicine Practitioner:

Innersource

777 East Main Street

Ashland, OR  97520

541-482-1800

http://www.innersource.net

[email protected] 

 

Your signature below indicates that you have read the information in this document, understand it fully, have discussed any questions or matters of concern with me and/or others, and agree to abide by its terms during our professional relationship.

 

_______________________________________ _____________

Print Name Date

 

_______________________________________

Signature

 
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