Psychedelic Therapy Form
LIABILITY
Limits of Confidentiality:
Threat to Self or Others:
All interactions which take place in the setting of therapy are considered confidential. This includes requests by telephone, all interactions with this counselor, any scheduling or appointment notes, all session content records and any progress notes that I take during your sessions. I will not even verify that you are a client. You may choose to give me permission in writing to release any or specific information about you to any person or agency that you designate.
Limits to this agreement In some legal proceedings a judge may issue a court order. This would require this counselor to testify in court. If I learn of or believe that there is physical or sexual abuse or neglect of any person under 18 years of age, I must report this information to county child protection services. If I learn of or believe that an elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency that handles elder abuse. If I learn of or believe that you are threatening serious harm to another person, I am obligated to report this. This can be in the form of telling the person who you have threatened, contacting the police or placing you into hospitalization. If there is evidence that you are a danger to yourself and I believe that you are likely to kill yourself unless protective measure are taken, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection. There may be times when I consult with outside sources about cases. Discussion topics will be used in order to ensure that I am getting and giving the best assistance possible. The persons with whom I discuss cases are legally bound to keep information confidential.
Child and Elder Abuse: The facilitators are mandated reporters and are required by law to report any instances of suspected child or elder abuse. Reports will be made to Child Protective Services or appropriate authorities as necessary.
Legal Subpoena: If a court issues a subpoena for case records or testimony, the facilitator will assert "privilege" on your behalf, where applicable. If the court denies this assertion, the facilitator will comply with the order. Records may also be released with your written consent.
Professional Consultation: Facilitators may consult with other professionals to better assist you in reaching your goals. No identifying information will be shared without your explicit consent.
Other Safety Factors:
Confidentiality: Members must maintain confidentiality to create a trusting environment beneficial for all participants.
Facilitator's Role: The group facilitator will maintain a respectful environment to ensure safety and trust.
Litigation Limitation:
Due to the confidential nature of the therapeutic process, you agree not to subpoena the facilitator to testify in court or any other legal proceeding, nor request disclosure of psychotherapy records, except as otherwise agreed upon.
Process of Therapy & Scope of Practice:
Participation in therapy, including ketamine-assisted psychotherapy, may yield benefits such as improved interpersonal relationships and resolution of specific concerns. However, these outcomes are not guaranteed, and the process may require significant effort and patience. The facilitator does not provide custody evaluation recommendations, prescription recommendations, or legal advice, as these are outside the scope of practice.
No Refund Policy:
Payments for participation in the ketamine-assisted psychotherapy retreat are non-refundable under any circumstances, including but not limited to the participant's decision to withdraw, changes in the participant's schedule, or any changes in staff or facilitators. By signing below, you acknowledge and agree to this no-refund policy.
Consent and Eligibility for Ketamine-Assisted Psychotherapy:
This consent form provides information on the use of sub-anesthetic doses of ketamine for psychiatric purposes, such as treating depression, anxiety, and PTSD. While ketamine is FDA-approved as an anesthetic, its use for psychiatric conditions is considered off-label. The administration of ketamine will be conducted by a licensed medical doctor with a Schedule III DEA license. The psychotherapist's role is supportive and does not include prescribing or administering ketamine.
By signing this form, you acknowledge understanding the potential benefits and risks associated with ketamine-assisted psychotherapy. You give informed consent to participate in this treatment. A copy of this signed form will be provided for your records.
Release and Waiver of Liability:
By signing below, you release and discharge Alexa Altman and Shira Myrow, their agents, employees, representatives, successors, and assigns, from any and all liability, claims, demands, actions, or causes of action related to any loss, damage, injury, including death, that may occur during your participation in ketamine-assisted psychotherapy. This includes any claims of negligence. You further agree to indemnify and hold harmless the released parties from any such claims.
Digital Signature Consent and Authorization:
Consent to Electronic Signatures: You consent to the use of electronic signatures and records.
Verification of Identity: You affirm that you are the individual identified in this document and that the information provided is accurate and true.
Acknowledgment of Digital Signature Act Compliance: This agreement complies with the E-SIGN Act and UETA.
Retention and Accessibility: You acknowledge your ability to retain a copy of this document.
Acceptance and Binding Nature: Your electronic signature indicates your agreement to the terms herein.
Governing Law and Venue:
This agreement is governed by the laws of the State of California. Any disputes will be resolved in the courts of [specific county], California.
Severability Clause:
If any provision of this waiver is found unenforceable, the remaining provisions will remain in effect.