Please carefully read the statements below and provide your signature.

 

1.  I understand that following yoga therapy advice is a voluntary, collaborative effort and that mutual agreement to begin does not in any way imply the Yoga Therapist’s guarantee of problem resolution or problem resolution in a specific time. I understand yoga therapy may bring up unforeseen changes in my physical, emotional, or mental nature.

 

2.   I understand that the yoga therapist will respect my confidentiality and not reveal information concerning my appointment(s) to anyone except as follows: a) I consent to release of information; b) the life or safety of myself or others is seriously threatened, to including any incidence of suspected suicide risk, child abuse, neglect or molestation; c) I file an insurance benefit claim, and the claims payer requires treatment information; d) the yoga therapist may discuss my case in consultation with a licensed health and/or mental health professionals who are also bound by confidentiality. 

 

3.  I understand that any touch used by the yoga therapist is for muscle or bone movement, to direct energy, or bringing my awareness to a part of my body.  All touch will be conducted only after and if I give verbal permission.  I understand that touch is a suggestion and that I may refuse touch and still receive a yoga therapy session that addresses my needs.

 

4.  I agree to sign release forms if I ask the yoga therapist to consult with my other professional providers.