CONCENT FORM - PLEASE SIGN OFF

Consent & Liability Disclosure Informed Consent to Treat and Liability Waiver & Release RELEASE OF ALL LIABILITY In exchange of the fee paid by you, Janet DeHart and affiliated facilitators are providing services assisting you in mind, body, spirit integration through the use of modalities that may include, but not limited to: Somatic release, Movement therapy, Intuitive readings, sound baths and healing, guided meditations and imagery, self-care suggestions, private consultations, and energy work. All information and mental or physical activity or guidance and direction are provided during programs, classes, cohort or private consultations to enhance the well-being of you, the participant. You, the participant, hereby agree to assume all risks associated with any outcome resulting from your participation in Janet DeHart's programs or classes or cohort or private consultation with their practitioners. Side effects may include, but not limited to: emotional release, lightheadedness, mild fatigue, dreams and memory activation, physical tingling, and change in body temperature. It is your responsibility, as participant, to inform the practitioner if any discomfort should arise. It is your responsibility, as participant, to notify the practitioner ahead of treatment of any pre-existing medical conditions or injuries. By signing this Waiver and Release of liability you agree that neither Janet DeHart nor practitioners or facilitators of Janet DeHart shall be responsible for any negative consequence of any kind which is claimed to result from: 1) your participation in any of these sessions, treatments, activities or consultations; or 2) from the use of any information learned or obtained during these sessions, cohorts, programs, activities or consultations, including, but not limited to, movement therapy, somatic release, acutouch, intuitive readings, reiki treatment, guided meditations and imagery, sound baths and healing, chakra healing, energy work, or private consultation provided during Janet DeHart sessions, cohorts, programs, classes, or private consultations. By signing this Waiver and Release you further agree not to assert any legal claims of any kind in any form against Janet DeHart on any asserted negative consequence resulting from your participation in these sessions, cohorts, programs, classes or private consultations. By signing this Waiver and Release you acknowledge and agree that Janet DeHart disclaims all liability for any injuries or negative consequence claimed by you to be the result of your participation in these sessions, cohorts, programs, classes, or private consultations. The Mission and Intent of Janet DeHart and Self Care Sovereignty It has long been my vision to provide community with a wellness space and services devoted to the art of holistic integrative healing. I understand there to be a strong connection between mind, body, spirit and the overall well-being of an individual. The individual is inherently connected to nature and the entire collective energy field. To that end, I employ techniques such as yoga, pilates, reiki, meditations, breathwork, acutouch, sound therapy and self-care consultations to promote awareness, vitality, and comprehensive harmony and balance. My motivation is to encourage an intentional journey of self-discovery, and activate expansion of consciousness that will contribute to life-long health and healing.

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Practice Policies

ABOUT THIS DOCUMENT

This document contains important information about my professional services and business policies and agreements concerning our work together. Please read it carefully and feel free to ask questions. Once you sign this document, it will become a binding agreement between us for the duration of our work together or until another replacement agreement is signed, and also provide your consent for us to begin therapy and counseling.

Mandatory Disclosure Statement:

THERAPY & EDUCATION

My qualifications and experience include individual, couples, family, and group therapy, counseling, coaching, and consulting. I hold multiple degrees and thousands of hours in continuing education in relational leadership, authentic relating, mind-body therapies, trauma, attachment, couples, and more. I hold a master’s degree in Social Work and practice as a clinical psychotherapist and coach. I utilize techniques from a variety of education and training areas, including but not limited to: Internal Family Systems (IFS), Gestalt, Authentic Relating, The Gottman Method, Somatic Experiencing (SE), EMDR, psychedelic integration, somatic psychology, attachment and systems theories, Eastern and Daoist practices, and relational leadership. I currently receive professional consultation and supervision from Jake Lohwater, LCSW.

The deeper scope of work may include the use of body-centered techniques and deep therapy, while some may be more like coaching, relational training, or awakening work. These approaches have the capacity to surface subconscious and implicit memories and insights. Therapeutic work may employ the use of “non-ordinary states,” and is therefore experiential and often evocative of non-verbal body and nervous systems states, along with relational patterns and mental-emotional content.

I draw from evidence-based methods and techniques. In addition, certain integrative approaches I practice are neither explicitly recognized nor validated by the Colorado Department of Regulatory Agencies (DORA), and are peripherally supported by research. Therefore certain aspects of my approach may still be considered experimental in nature. This provides us the opportunity to utilize best practices and follow what works.

ETHICS

To maintain professionalism, I refer to ethical guidelines set forth by professional organizations to formulate standards of care. In a professional relationship, sexual intimacy is never appropriate. All therapeutic touch techniques used between therapist and client are with your awareness and consent, without sexual or romantic intent.

Therapy and the relationship with a therapist may elicit certain types of bonding that can be helpful for creating a trusting healing environment and especially healing attachment wounds. Also, projection and challenges can arrise that have the possibility of making continued therapy feel difficult. This is typically a normal and expected part of the process. You have a right to terminate therapy at any time. I encourage you to discuss any challenges that arise with me directly, even if this seems challenging or foreign, because this is a huge opportunity to alter old behavior patterns that come from our wounding (and/or fear of expressing our truth in connection). I require at least one session prior to termination where we can examine if the termination is appropriate, if a reference to another practitioner is needed, or if something difficult came up and this road block is a significant pattern that can be healed through the relational contact and create new and unexpected doorways to realization and connection.

PROFESSIONAL REGULATION

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Professions and Occupations. The Board of Registered Psychotherapists can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. As to the regulatory requirements applicable to mental health professionals: Registered Psychotherapist is a psychotherapist listed in the State's database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience. Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience. Certified Addiction Counselor III (CAC III) must have a bachelor’s degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience. Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements. Licensed Social Worker must hold a master’s degree in social work. Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master’s degree in their profession and have two years of post-master’s supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision.

CONFIDENTIALITY

Generally speaking, the information provided by and to the client during therapy sessions is legally confidential and cannot be released without the client’s consent. I am also considered a mandatory reporter, which means there are certain exceptions to this confidentiality. Please refer to 12-43-218 of the Colorado Revised Statutes, and the HIPAA Notice of Privacy Practices as well as exceptions in Colorado and Federal Law. Some circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled. If a legal exception arises during therapy, if feasible, you will be informed accordingly. Additional information about confidentiality is included in subsequent pages of this document.