Outdoor Release/Waiver — The Unselfish Journey

Outdoor Participation Agreement

Information

Policies and practice agreement - Release and waiver of liability - Assumption of risk - Indemnity Agreement

Policy and practice agreement

Notice of policies and Practices to protect your Privacy

The following is a sample of a document that I will ask you to sign before beginning any outdoor group therapy. Please read it carefully and discuss any questions you may have with me. When you sign the document, you will be stating that I provided you with this information and it will represent an agreement between us.

OUTDOOR THERAPY SERVICES

As with indoor therapy taking place in an office, outdoor therapy varies depending on the therapist, the group and the group’s particular situations and goals. In order for therapy to have the best outcome, you will have to invest energy in the process and work actively on things we talk about both during and between our sessions.

Outdoor group therapy can have benefits and risks. The risks may include experiencing uncomfortable feelings like sadness, guilt, anger, anxiety or frustration when discussing aspects of your life. Psychotherapy has been shown to have benefits that can include better relationships, solutions to specific problems, increased life satisfaction, improved physical health, and significant reductions in feelings of distress. However, it is impossible to predict or guarantee what you will experience.

You voluntarily choose to participate in outdoor group therapy because you believe it may be helpful to your own personal growth and development. You are not participating in outdoor group therapy because of pressure from anyone else. I take full responsibility for communicating and maintaining my personal boundaries and acknowledge that I am not a personal trainer, medical doctor, nurse nor nutritionist.

You acknowledge that participation in outdoor group therapy involves both known and unanticipated risks that could result in physical or emotional injury or damage to yourself or others. You understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of outdoor group therapy. These risks include but are not limited to: emotional stress or trauma, strenuous and vigorous physical, mental and intellectual activity; the possibility of slips, falls, bruises, sprains, lacerations, fractures, animal bites or bee stings, concussions or even more severe life threatening hazards, including death.

Time Frame

An outdoor group therapy experience usually lasts from a half day to a full day, depending on how long the outing is scheduled for. If you ever need to cancel your participation in an outdoor group therapy outing, please do so at least 48 hours in advance. If you do not cancel a scheduled participation with at least 48 hour notice or if you fail to attend a scheduled outdoor group therapy outing, you will be expected to pay the full fee for that time, unless we both agree that you were unable to attend due to circumstances beyond your control.

Professional Fees

Outdoor group therapy will cost $100 for a 1/2 day, and $200 for a full day. This fee includes snacks, first aid, and materials.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep treatment records. You are entitled to examine and/or receive a copy of your records if you request it in writing unless I believe that seeing them would be emotionally damaging, in which case I will send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/ or be upsetting to people who are not mental health professionals. In order to see your records, we will need to discuss the contents together. I reserve the right to charge you for the costs of copying and sending your records if you request them.

CONFIDENTIALITY

Your mental health information is confidential; however therapists are mandated reporter’s which means that in all certain circumstances, I am required by law to release information without your consent.

These situations are described below. Please read these situations and feel free to ask any questions about them.

If you make a specific threat to harm yourself or someone else (and the risk of danger is deemed imminent), I must take appropriate steps to protect you or warn the appropriate parties.
If I suspect you have physically or sexually abused or neglected a child or vulnerable adult, I must make a report to the proper authorities. This includes some cases of domestic abuse when a child is exposed to weaponry or is physically threatened and/or used as a weapon.
If you are pregnant and using a controlled substance, such as heroin, cocaine, phencyclidine, methamphetamine, or their derivatives.
When there is a court order to release your records to the legal authorities.

Because outdoor group therapy is conducted outdoors in public places, you understand that there are confidentiality risks and consequences to your participation. One of us may encounter another person that we know and another person may overhear what we are saying.

While I am not an attorney, please discuss any questions or concerns you have about confidentiality with me at any time. If you have specific legal questions about the laws regarding confidentiality, the exceptions, and how it may relate to your situation, please seek formal legal advice from an attorney.

CONCLUSION

I reserve the right to change the policies, practices and procedures described in this document. I will notify you in writing of any significant changes. By signing this Therapy Agreement, you are indicating that you have received and read the information in this document, you have discussed the contents with me to your satisfaction, and you agree to abide by its terms during the course of our professional relationship.

Release and waiver of liability - Assumption of risk - Indemnity Agreement

I _________________ (name) am registering for the following trip _________________________.

By completing this form, you are indicating that you have chosen to voluntarily participate in outdoor group therapy offered through Deborah B. Edgar, MFT Psychotherapy & Counseling Services. Activities vary and may include, among others, walking and hiking mountainous terrain. You further understand and acknowledge that the activities in outdoor group therapy have risks, including certain risks which are inherent. Inherent risks are those which cannot be eliminated without destroying the unique character of these activities. You understand that all types of bodily injury and disability, including death, are a risk to participating in these activities. You understand that Deborah B. Edgar, PhD, LMFT, Deborah B. Edgar, MFT Psychotherapy & Counseling Services, or any Intern under their charge assumes no responsibility or liability for your participation in this outdoor group therapy, and you agree to assume all the risks of participating.

I __________________ (name) understand and voluntarily agree to release, waive, and agree not to sue Deborah Edgar, PhD, LMFT, Deborah B. Edgar, MFT Psychotherapy & Counseling Services, or any Intern under their charge, for any and all claims, damages, costs, attorney's fees, or causes of action which I have or may in the future, as a result of damages or injuries relating to the participation or travel to and from the outdoor activity, arising out of or incident to any negligent act or omission by Deborah Edgar, PhD, LMFT, Deborah B. Edgar, MFT Psychotherapy & Counseling Services. I knowingly give up valuable legal rights, including the right to sue.

I __________________ (name) understand and agree that there exist risks of harm associated with participating in an outdoor therapy group which may give rise to bodily injury and/or property damage. These risks include, but are not limited to, equipment failure, inadequate safety equipment, those hazards associated with strenuous activity, the unavailability of adequate medical care, exposure and emergencies related to heat or cold weather, personal injury including physical and/or mental trauma or death, exhaustion, dehydration, broken bones, concussion, torn appendages, dislocations, bruises, cuts, infections, and any other injuries that may result in physical contact with others. I further understand and agree that there may be risks and dangers not known or reasonable foreseeable at this time. I understand that outdoor group therapy will consist of mild to moderate hiking. I understand and agree that included within the scope of this waiver and release is any cause of action, arising from the failure to warn of existing dangerous conditions not known to or reasonable discovered by Deborah Edgar, PhD, LMFT, Deborah B. Edgar, MFT Psychotherapy & Counseling Services, or any Intern under their charge. I, and/or the negligence of other group members, may cause these risks and dangers.

I knowingly and voluntarily assume full responsibility for these risks arising out of or related to my participation in outdoor group therapy.

I HAVE CAREFULLY READ, AND I UNDERSTAND, ACKNOWLEDGE AND AGREE TO THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT. I UNDERSTAND THAT I AM GIVING UP VALUABLE LEGAL RIGHTS BY SIGNING THIS AGREEMENT, AND THAT THIS AGREEMENT REPRESENTS A CONTRACT BETWEEN DEBORAH B. EDGAR, MFT PSYCHOTHERAPY & COUNSELING SERVICES AND MYSELF. I HAVE VOLUNTARILY CHOSEN THE ACTIVITIES IN WHICH I AM PARTICIPATING.

Address___________________________________________________________________________________________________

Phone #_____________________________ Age ______________________

Please Check One of the Following:

I have medical and accident insurance with ___________________________________ Policy # ____________________
I have no medical or accident insurance, and I agree to pay and medical and/or dental expenses directly or indirectly related to my participation.

Printed Name of Participant _________________________________________________ Date ______________________

Participant Signature ______________________________________________________