Yoga Consent Form

Your Email Address*

So we can send a copy to you after it's signed.

I HERE BY AGREE TO THE FOLLOWING: Am aware that participation in psychotherapy, a workshop, or Yoga (sometimes called a sport, form of relaxation, or mindfulness exercise) can arouse emotional distress, pain, or injury, and by attending the client assumes the risk connected with the voluntary participation in these activities. I am aware this office is pet friendly, and you are accepting of this. I am also aware that participating by Zoom or telephone can involve internet difficulties which is not Dr. Shafer’s responsibility.

Voluntary or mandatory participation in psychotherapy, a workshop, or Yoga represents that you are in good physical health, and/or have obtained approval from a health care provider. This means that I have NO physical or emotional impairment which would limit my participation in these activities live in the office or by Zoom.

I also understand I will not cease any medical treatments or assume psychotherapy or yoga can replace such treatments or use of prescribed medications. I acknowledge that Dr. Shafer has not and will not render any medical services including a medical diagnosis of my physical condition or prescribe supplements. I specifically agree that Limitless Potentials, its psychotherapists, employees, and yoga instructors shall not be liable for any claim, demand, cause of action of any kind resulting from or related to the my participation in psychotherapy, a workshop, Yoga or Yoga Therapy, or any mindfulness exercise, and I agree to hold Limitless Potentials, Dr. Shafer and staff harmless from the same whether live or by Zoom.

While having a session with Dr. Shafer over Zoom, Facetime, or over the phone is helpful when it is not possible to meet live in her office, due to Covid or other restrictions (out of town, etc) technology is not without problems. Please sign on 10-15 minutes early for your appointment, or call her if you have not received the Zoom or conference call email invite: 561-799-6789.

Before your session begins, please make sure your room is secure for privacy, so you will not be interrupted. Dr. Shafer recommends you create with her a code word or phrase like "I wish I was at the beach right now" or "I need to get back to my homework" in the event someone walks into the room, or you are interrupted, and no longer have privacy, and/or you need to suddenly stop the session. Also, sometimes clients get dropped during Zoom sessions which is not Dr. Shafer's fault or responsibility for either situation. If this happens please call her 561-799-6789 so you can complete/resume your session with her over the telephone. It is also requested and assumed that you are not under the influence of drugs or alcohol (including marijuana), or drinking alcohol or smoking marijuana during your telehealth session. If Dr. Shafer suspects you are under the influence and this is confirmed the session may have to be rescheduled at your expense.

Agreement to above terms*

I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

Client's Name*

First Last

Date of birth*

Is participant under 18?

Yes

I rate my overall health as:*

excellent
good
fair
awful

Date*

Patient Consent

As legal guardian, I consent to the above terms and conditions.*

Yes

Parent/Legal Guardian’s Name*

First Last

Date*

Parent/Legal Guardian Consent

List any health concerns or limitations:

Patient's or Guardian's Signature*

Name

This field is for validation purposes and should be left unchanged.

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