GENERAL INFORMATION

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for Inclusion Therapies LLC, EIN #87-1279667, Type 2 Group NPI #1801421482 (hereinafter "Inclusion Therapies” or “IC"), and therapy client to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together.  The outcome of your treatment depends largely on your willingness to engage in this process. 

1. CONSENT TO TREATMENT

(BEHAVIORAL, PSYCHOLOGICAL, PHYSICAL)

A. I, client (or Legally Authorized Representative of client), have presented myself to Inclusion Therapies (IC) for therapy treatments and consent to the care (history, physical examination, treatment, etc.) that will be provided by my therapist and assistants/technicians. I acknowledge that Recreational Therapy is “a systematic process that utilizes recreation and other activity-based interventions to address the assessed needs of individuals with illnesses and/or disabling conditions, as a means to psychological and physical health, recovery and well-being. Further, "Recreational Therapy” means a treatment service designed to restore, remediate and rehabilitate a person’s level of functioning and independence in life activities, to promote health and wellness as well as reduce or eliminate the activity limitations and restrictions to participation in life situations caused by an illness or disabling condition.” (https://www.atra-online.com/page/AboutRecTherapy) 

B. I realize I have the right to refuse any treatments or procedures to the extent permitted by law. I acknowledge that the delivery of healthcare does not guarantee results of any treatments. Mental and behavioral health therapy will include client discussion of personal issues which may bring up uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh this discomfort and can lead to benefits such as improved personal relationships and reduced feelings of emotional distress. I understand that while this mental/ behavioral health recreational therapy may be beneficial, as with any treatment, there are inherent risks. I acknowledge, however, that no warranty or guarantee can be made as to the results of therapy. 

For treatment of a physical disease, injury or disability; I acknowledge that the recreational therapist will integrate activities that incorporate rehabilitative procedures, mobilization, massage, exercises and physical agents to aid in recovery, reduce the length of functional impairment and achieve optimal potential.

I acknowledge that Inclusion Therapies only hires provider therapists that are professionally qualified (e.g., have a verified license or certification credential attesting that they have a bachelor’s, master’s or doctorate degree in their field of study, have completed a clinical internship and have passed a competency exam; such as a Certified Therapeutic Recreation Specialists or CTRS). I accept the treatment recommendation of my Recreational Therapist. I further certify that my Recreational Therapist has informed me of the nature and character of the proposed treatment, alternative treatment choices, and the possible risks, complications, and anticipated benefits involved in the proposed therapy. I understand that I may stop such treatment or services at any time.

C. I understand that information from any medical record(s) kept by Inclusion Therapies may be used for educational, administrative, and/or organizational approved purposes.

D. I hereby authorize the release of medical information necessary to process my insurance or other third-party payer and authorize payment directly to the provider of service. I am responsible for any services not covered by this authorization. I have read and fully understand the Patient Financial Responsibilities Form. 

E. For Worker's Compensation clients: I hereby authorize Inclusion Therapies to receive my records related to my work injury.

2. WAIVER

A. I have read this consent form and understand the risks involved in Recreational Therapy and agree to fully cooperate, participate in all Recreational Therapy procedures, and comply with the established plan of care. The therapy as stated, including the possible risks, complications, options, and expectations have been explained to me, my representative or legal guardian (if a minor or ward) and consent is thus given as noted by signature on this document. I grant IC provider(s) the authority to sign consent waivers and/ or releases on my behalf to permit activity participation for my client/ward for activity interventions prescribed during the course of delivery of Recreational Therapy healthcare services. 

B. There are risks inherent with Recreational Therapy activity interventions including aquatic (or hydrotherapy), nature (or ecotherapy) and other interventions including, but not limited to: playing games, running, walking, sports, biking, roller skating, ice skating, trampolines, fishing, tennis, dancing, virtual reality, electronic gaming, cooking, weightlifting, cardiovascular exercise, wood working, sewing, et cetera.

3. RELEASE

In consideration for Recreational Therapy services by Inclusion Therapies (IC), I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS IC, its employees, officers, agents, directors and volunteers and owners Robert Broadhead and Courtney Anderson Broadhead (jointly and individually) (hereinafter referred to as RELEASEES) form any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or personal injury, including, but not limited to, illness or death, that may be sustained by myself and/or my child/ward, or to any property belonging to myself and/or to my child/ ward, while engaged in therapy at IC, irrespective of physical location of myself and/or my child/ward.

4. ASSUMPTION OF THE RISK

I am fully aware of the risks and hazards connected with myself and/or my child/ward participating in Recreational Therapy activities or allowing myself and/or my child/ward to play around activity locations, events or environments (including but not limited to pools, outdoor trails, lakes, ponds, parks, playscapes, boats, trampolines, skating rinks, bike and skate parks, cooking equipment, computer equipment, sports, etc.); including the risk of physical injury or disability as the result of such injury, and I am voluntarily allowing myself and/or my child/ward to participate in said Recreational Therapy activity, and to enter the premises of IC (or other third party activity locations) to engage in such activity. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY that may be sustained, or any loss or damage to property as a result of being engaged in such activity. 

I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damages, judgments, suits, claims costs, attorneys’ fees or costs that may incur due to myself and/or my child’s/ward’s participation in Recreational Therapy with Inclusion Therapies. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assignees and personal representative, if I am not alive, and shall be deemed as a RELEASE, WAIVER, AND DISCHARGE of the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Texas. 

I agree to fully and forever waive, release and discharge IC from any and all claims, actions, causes of action, demands, judgments, damages (including compensatory, general, special, consequential, exemplary and punitive), liability or obligations of any nature or kind, whether known at the time of delivery of recreational therapy healthcare service or which may arise or become known later, which accrue on account of, or in any way arise out of or in connection with:

I understand that the RELEASEES will not be responsible for any medical costs associated with any injury. I agree to indemnify and hold IC harmless from and against any and all losses, liabilities, claims, obligations, costs, damages, and/or expenses whatsoever, including, but not limited to, any and all attorneys' fees, costs, damages and/or judgments directly or indirectly arising out of, or relating to client acts or omissions while participating in any activities related to the delivery of healthcare services by IC. Client agrees to accept and assume all of the risks which accompany IC’s healthcare and wellness service delivery activities and represent that client's participation in the activities is purely voluntary and client elects to participate in the activities notwithstanding the risks; and client certifies that client has adequate insurance to cover any injury or damage client may cause or suffer while participating in the activities within the scope of healthcare and wellness service delivery by IC, or if not, client agrees to bear the costs of such injury or damage to client and others.

5. CONSENT TO MEDICAL TREATMENT

(MYSELF AND/OR OF MINOR)

Client, and/or client Legally Authorized Representative (LAR), hereby gives my permission that the IC staff is authorized to give myself and/or my child/ ward participant reasonable first aid, or if myself and/or my child/ward should require emergency medical or surgical treatment, I/he/she may be treated at the nearest emergency facility by the physician in attendance and any other health care professionals to consult. I hereby authorize IC and their authorized representatives to disclose any of my own and/or of my child/ward's health-related information to any healthcare provider and I consent to the admission of the activity participant to the hospital, the administration and performance of all examinations and the administering of medicine, treatment, anesthetics, operations, x-rays or other procedures which the physicians attending the participant deem necessary for the emergency care and treatment of the participant. I hereby agree to accept responsibility for any financial indebtedness occurring in transport, in the emergency room, or clinic treatment of the participant at the emergency facility utilized. Further, I understand that, upon my, and/or my representative’s, arrival at the hospital, I, and/or my representative, will authorize continued medical care.

6. COMMUNICATION

I consent to receive information (such as appointment reminders, patient surveys, and other information relating to Inclusion Therapies services) via the communication channels for which I provided the contact information including via phone, text, and email. I may opt out of communication at any time by informing Inclusion Therapies in writing (via email at Info@IncThr.com, text at (512) 553-5380 or mail to: 2110 Ranch Road 620 S, #341225, Lakeway, Texas 78734) of my communication preferences. By providing your phone number to us, you agree to receive text messages from Inclusion Therapies LLC. Message and data rates may apply. Message frequency varies. Text STOP to opt-out at any time.

7. NOTICE OF PRIVACY PRACTICES

By signing this form, I acknowledge that Inclusion Therapies has made its HIPAA Privacy Notice available to me, which explains how my health information will be handled in various situations. I understand that I may discuss my concerns and/or any questions I have concerning this Privacy Notice with Inclusion Therapies representatives. 

8. CONFIDENTIALITY

A. The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. 

B. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. Duty to Warn/ Duty to Protect: If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally, therapist may need to consult with other professionals in their areas of expertise in order to provide the best treatment for client. Information about client may be shared in this context without using client’s name. 

If therapist and client see each other accidentally outside of therapy office, therapist will not acknowledge client first. Client’s right to privacy and confidentiality is of the utmost importance to Inclusion Therapies, and therapist does not wish to jeopardize client privacy. However, if client acknowledges therapist first, therapist will reciprocate.

9. TELEHEALTH THERAPY CONSENT

A. I, and/or the minor(s)/ward(s) that I serve as a Legally Authorized Representative (LAR) for, understand that my health care provider Inclusion Therapies wishes me to engage in a telehealth therapy session.

1. My health care provider explained to me how the online video conferencing and/ or phone technology that will be used to affect such a therapy session will not be identical to as a direct client/health care provider visit due to the fact that I will not be in the same physical room as my provider.
2. I understand that telehealth therapy has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth therapy consult/visit if it is felt that the online videoconferencing and/ or phone connections are not adequate for the situation.
4. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

10. CONSENT TO USE THE TELEHEALTH TECHNOLOGY PROVIDER

Inclusion Therapies uses technology third party service providers to conduct telehealth videoconferencing and/ or phone appointments.

A. By signing this document, I acknowledge:

1. Telehealth providers are NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
2. Though my healthcare provider and I may be in direct, virtual contact through the Telehealth Service, the Telehealth Services do not provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
3. The Telehealth Service facilitates videoconferencing and/ or phone services and are not responsible for the delivery of any healthcare, medical advice or care.
4. I do not assume that my provider has access to any or all of the technical information in regard to the Telehealth providers – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any technical expertise or knowledge of the technical requirements for delivery of online video and/ or phone Telehealth by any third-party vendor or provider.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

11. TRANSPORTATION RELEASE & WAIVER

Participation in Recreational Therapy activities included in the Inclusion Therapies treatment plan and/or educational curriculum may involve travel to location sites for activity participation. As a courtesy, solely at the discretion of Inclusion Therapies, IC may facilitate travel by privately owned vehicles or IC owned vehicles driven by employees, managers, volunteers, contractors, owners or agents of IC.

I, the undersigned client, certify that the above statement has been read and I hereby consent to the transportation of client to and/or from activities in privately owned vehicles or IC owned vehicles operated by IC employees, managers, volunteers, contractors, owners or agents of IC. I, the undersigned, hereby release Inclusion Therapies and all employees, managers, volunteers, contractors, owners or agents acting on behalf of Inclusion Therapies from all liability for any adverse outcome that may occur during (or immediately preceding or after) transportation. I understand that I have the right to revoke this authorization at any time. I understand I must do so in writing (via email, text or mail) to Inclusion Therapies. Transportation of client is not the responsibility of Inclusion Therapies and will not be relied on by client and/or client parent/ guardian. Transportation will be on a case-by-case basis and may be revoked solely at the discretion of Inclusion Therapies for any reason at any time.

12. ARBITRATION & DISPUTE RESOLUTION

In the event that a disagreement arises between IC and client (and/or client representative), which we are not able to satisfactorily resolve between us, then client hereby agrees that any and all disputes, controversies, claims, or demands arising out of or relating to this agreement, our relationship with you, or our performance of any current or future healthcare or wellness services, will be resolved exclusively by submission to binding arbitration in Austin, Texas for resolution. This is for any and all disputes arising under or relating to this contract or the engagement and healthcare services to be rendered, including but not limited to malpractice claims or any others.

Arbitration is to be conducted under the Texas Arbitration Act in accordance with the laws of the State of Texas. Arbitration costs will be allocated evenly among the involved parties. The arbitrator will have the authority to award any relief that a judicial court would have the jurisdiction to grant. The arbitrator will be permitted to award attorney’s fees as he or she deems necessary and just. Both IC and client intend and agree to be bound by this provision and the results of such arbitration. Client understands and agrees that it has the right to consult independent counsel regarding this provision and that if accepted, this provision will eliminate clients’ right to a jury trial in any and all disputes.

13. PERFORMANCE

This Agreement is performable in Austin, Travis County, Texas. Jurisdiction and venue of any dispute arising hereunder are also performable in the city of Austin, Travis County, Texas. Client agrees that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. 

14. PHOTO/VIDEO AUTHORIZATION

Client grants to Inclusion Therapies and its affiliated entities, and its representatives and employees (collectively the “Company”) the right to take photographs and\or videos of client in connection with participation in therapy services. Client authorizes the Company, to copyright, use and publish the same in print and/or electronically. Client agrees that the Company may use such photographs of client only without their name, face, or other identifying characteristics fully visible; and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content (and waive any right to compensation therefore). Client understands that they may revoke this authorization but only in writing (via email, text or mail) delivered to the clinic administrator. Client understands that if they choose to revoke this Authorization, the revocation will not be effective for any uses and/or disclosures of their protected health information that have already been made in reliance on this Authorization. 

15. ELECTRONIC MONITORING

Inclusion Therapies requires that clients and visitors do not take any photos or make any video recordings that disrupt client care or puts the privacy of other clients and families at risk. Health care providers and staff members must give consent before being photographed or recorded by anyone.

In order to promote the safety of employees, clients and visitors, as well as the security of its facilities, Inclusion Therapies may conduct electronic monitoring via video surveillance of any portion of its premises at any time, the only exception being private areas of restrooms. Video cameras will only be positioned in appropriate places within and around Inclusion Therapies’ buildings and used in order to help promote the safety and security of people and property. There is no public access to any live stream or recordings. Only the Administrative and Clinical Directors have access to the video files which are stored locally. The recordings are confidential and may not be used for any purpose other than promoting the safety of clients, staff and visitors. I hereby give my consent to such video surveillance at any time Inclusion Therapies may choose and release Inclusion Therapies from all liability, including liability for negligence, associated with the enforcement of these policies and/or any searches and/or monitoring surveillance undertaken pursuant to these policies.

16. PREMISES SAFETY AND SECURITY

Inclusion Therapies strives to promote the health and healing of everyone and therefore no drugs, unauthorized use of prescription medication, alcohol or smoking any substance including, but not limited to, tobacco products (including, but not limited to, cigarettes, e-cigarettes or vaping devices, pipes, cigars, snuff, or chewing tobacco); possessing or carrying weapons are not allowed anywhere on our premises.

17. AUTHORIZATION

I acknowledge, as indicated by my signature below, that I have read and fully understand this Client Informed Consent; Waiver, Release & Assumption of the Risk; Consent to Medical Treatment (including of Minor/Ward); Privacy Notice, ADR, Consent to Teletherapy & Transportation; Authorization Communication & Photo/ Video, Electronic Monitoring, Premises Safety and Security, Acknowledgment for Recreational Therapy (including Aquatic Hydrotherapy, Nature Ecotherapy).

By signing this form, I am acknowledging my understanding of the "HIPAA Notice of Privacy Practices" and authorizing persons listed on the Information Release (herein as Exhibit A) to receive my health information.

 BY SIGNING, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO ALL OF THE TERMS CONTAINED IN THIS DOCUMENT. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I HAVE READ THE FOREGOING WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT, UNDERSTAND IT AND CONFIRM THAT NO STATEMENTS OR INDUCEMENTS, APART FROM THE FOREGOING WRITTEN AGREEMENT, HAVE BEEN MADE; I AM AT LEAST EIGHTEEN (18) YEARS OF AGE AND FULLY COMPETENT; AND I EXECUTE THIS RELEASE, ON BEHALF OF MY CHILD/WARD, FOR FULL, ADEQUATE, AND COMPLETE CONSIDERATION; FULLY INTENDING TO BE BOUND BY SAME.