Tuesday, 16 June 2020 13:18

Informed Consent COVID -19

Written by 

Integrative Yoga Therapy For Wellness


This document contains important information about our decision (yours and mine) to resume in-person services in the light of the COVID-19 public health crisis.  Please read this carefully and let me know if you have any questions.  When you sign this document, it will be an official agreement between us.

Decision to Meet Face-to-Face

We have agreed to meet in person for some or all future sessions.  If there is a resurgence of the pandemic or if other health concerns arise however, I may require that we meet via telehealth.  If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues.  You understand that if I believe it is necessary, I may determine that we return to telehealth for everyone's well-being, if you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate.  Reimbursement for telephealth , is between you, and per your insurance provider.

Risks of Opting for In-Person Services
You understand that by my coming to your home, I am assuming the risk of exposure to the coronavirus.  This risk may increase if I have to travel by public transportation, as opposed to in my private vehicle.

Your Responsibility to Minimize Your Exposure
To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, our families, and other clients, safer from exposure, sickness and possible death.  If you do not adhere to these safeguards, it may result in our starting/returning to a telehealth arrangement.  Initial each to indicate that you understand and agree to these actions:

  • You will only keep your in-person appointment if you are symptom free_____
  • If you have a fever, or if your temperature is elevated (100 farenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth.  If you wish to cancel for this reason, I won't charge you a cancellation fee_____
  • You and I agree that I will not appear earlier than 5 minutes before our appointment time____
  • You will wash your hands or use alcohol-based sanitizer before I enter you home____
  • You will adhere to the safe distancing precaution of 6 ft in our practice room____
  • You and I will both wear a mask throuhout our session____
  • You will keep a minimum distance of 3-6 feet (1-2m.), and there will be no physical contact____
  • You will try not to touch your face or eyes with your hands.  If you do, you will immediately wash or sanitize your hands____
  • If you have a child, you will make sure that your child follows a hand washing and sanitizing protocol____
  • Your child will stay in a separate room from the practice room____
  • You will take steps between appointments to minimize your exposure to COVID____
  • If your job exposes you to people who are infected, you will immediately let me know____
  • If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me know____
  • If a resident of your home tests positive for the infection, you will immediately let me know and we will then (begin)resume treatment via telehealth__

 I may change the above precautions if additional local, state, or federal orders or guidelines are published.  If that happens, we will talk about any necessary changes.

My Committment to Minimize Exposure

My practice has taken steps to reduce the risk of spreading the coronavirus in my home and I have posted my efforts on my website.  Please let me know if you have any questions about these efforts.

If You or I are Sick
You understand that I am committed to keeping you, me, and all of our families safe from the spread of this virus.  If I show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will leave your home immediately.  We can follow up with services by telehealth as appropriate.  If I or a family member test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

Your Confidentiality in the Case of Infection

If you have tested positive for the coronavirus, I may be required to notify local health authorities.  If I have to report this, I will only providce the minimum informtion necessary for their data collection and will not go into any details about the reason(s) for our visits.  By signing this form, you are agreeing that I may do so without an additional signed release.

Informed Consent:  This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.

Your signature below shows that you agree to these terms and conditions.


____________________                                                ___________________

Client                                                                           Date


_____________________                                              ___________________

Yoga Therapist                                                              Date

Brenna Jacobson (C-IAYT)            tel:  604-369-8785       This email address is being protected from spambots. You need JavaScript enabled to view it.














Brenna is a (C-IAYT) Certified Yoga Therapist under the International Association of Yoga Therapists, a Certified Pelvic Floor Rehabilitation Specialist including Pfilates Therapy, Certified Pre-Post Part Consultant, Certified Trauma Sensitive Yoga Therapist, with other specialties, Meditation for Teens and Adults including I-Rest and Para Yoga Nidra and Mindful Meditation for Children and Teens, Restorative and Yin Yoga, and integrates Ayurveda Lifestyle life coaching. She has been teaching for more than 8 years in the Lower Mainland and Fraser Valley areas. She does home visits that include small groups and privates or teaches from her small studio.IAYT CertifiedYogaTherapist Large Logo
IAYT CertifiedYogaTherapist Large Logo

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Website: www.integrativeyoga.ca

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