INFORMED CONSENT STATEMENT

This Informed Consent Statement is part of the contract entered into between the polarity therapy helping professional, Carly Rainé Canant / Calm Pond Polarity, and the participating client for any private session work.

By entering into this practice with Carly Rainé Canant / Calm Pond Polarity, you understand:

  • Carly Rainé Canant is not a licensed physician.

  • The treatment approach (Polarity Therapy) is alternative / complementary to healing arts services which are licensed by the State of Montana.

  • There is currently no licensure for Polarity Therapy in the State of Montana. Work is governed by the Standards for Practice and Code of Ethics maintained by the American Polarity Therapy Association and the Ethical Guidelines maintained by the International Polarity Education Alliance.

Theory of Treatment & Nature of Services

This practice operates from a holistic model for health that supports physical, mental, and emotional wellness. Interventions used in this system include:

  • Verbal interaction which may include guided meditation and somatic exploration (using one’s awareness to bring attention to one’s internal experience of the physical body and vital energy system), inquiry into the client’s overall experience, sensation and perceptions, verbal exercises and dialogue that support self-awareness and energy balancing.

  • Client education concerning nervous system regulation and stress management, holistic diet and nutrition, movement education, stretching, and exercises that support energetic balance and regulation.

  • (In-person sessions only) Manual interventions such as touch therapy and physical contact with the body are used to support nervous system regulation and energy balancing. The client remains clothed during touch work. Touch therapy is intended to feel safe, comfortable, non-invasive, and non-aggressive at all times, without any sensual, erotic, or sexual undertones.

    Consent for receiving touch therapy may be withdrawn at any time by verbally alerting the polarity therapy helping professional.

It should be understood this system is complementary healthcare. The polarity therapy helping professional does not diagnose, prescribe for, or make therapeutic claims for any specific illness, condition, or disorder. The intent of the work is to support the holistic health of the whole body-mind system, and the resources within the client’s body-mind system for self-healing.

This holistic health practice is not a replacement for medical care, psychotherapy or psychiatry, physical therapy or massage, yoga instruction, work with a nutritionist or dietician, or any other form of licensed healthcare. If the participating client has any health concerns they should consult an appropriately licensed healthcare provider prior to engaging in this work.

Carly Rainé Canant assumes no legal liability for the individual’s participation in session work or for the participant’s application of any material learned in session work.

Qualifications

Carly Rainé Canant’s qualifications include the following credentials:

  • Level 1 Training–Graduate; Level 2 Training–Advanced Student (Polarity Therapy Institute)

    • Associate in Polarity Principals (Certified by the American Polarity Therapy Association)

    • Energy Principles Practitioner (Certified by the International Polarity Education Alliance)

  • Master’s Degree in Counseling Psychology / Expressive Arts Therapy (California Institute of Integral Studies)

  • Bachelor’s Degree in Psychology (University of California at Berkeley)

Payment Policy

Private Sessions —payment is due prior to or at the start of the session. Late payment may be pre-arranged. Accounts that remain unpaid/past due more than 14 days will incur a $50 servicing fee and be passed on to a debt collections agency.

Cancellation Policy

The client may cancel the appointment with more than 24-hours notice for no fee. Sessions canceled or rescheduled with less than 24-hours notice (or no shows) require payment of the full fee.

For in-person sessions, if you are exhibiting any symptoms of COVID-19 or have had exposure or potential exposure to COVID-19, please reschedule your session; The 24-hour cancellation policy is waived in these circumstances.

Confidentiality

All session work is held in confidence. If I am seeing another client whom you referred or who referred you, nothing is shared in either direction about our work together. Confidentiality may be breached in the following circumstances:

  • Where required by law (for example if I were subpoenaed to testify in a court case), I may be obliged to disclose details of our work together;

  • With your consent, I may share details about our work together with another care provider identified by you;

  • If you express an intent to seriously harm or kill yourself, or another person, I am obliged to report it to legal authorities;

  • I may discuss your case with a clinical supervisor but your identity will remain anonymous and wherever possible details about your person will be guarded to not reveal your identity.

I maintain digital records of our sessions that are only identifiable by your initials.

Carly Rainé promotes authentic presence and integrative wellness through polarity therapy and expressive arts workshops and classes in Eureka, Montana and online.

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