Informed Consent Authorization
1) Rocksteady Life-Client Relationship
A. The Client is solely responsible for creating and implementing their own physical, mental and emotional well-being, decisions, choices, actions and results arising out of or resulting from our relationship and their calls and interactions with Rocksteady Life. As such, the Client agrees that Rocksteady Life is not and will not be liable or responsible for any actions or inaction, or for any direct or indirect result of any services provided by Rocksteady Life. The Client understands that a session with Rocksteady Life is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease.
B. The Client further acknowledges that he/she may terminate or discontinue the relationship at any time.
C. The Client acknowledges that working with a Life Doula is a comprehensive process that may involve different areas of their life, including work, finances, health, relationships, education and recreation. The Client agrees that deciding how to handle these issues, incorporate doula principles into those areas and implementing choices is exclusively the Client’s responsibility.
D. The Client acknowledges that seeing a Life Doula does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association and that sessions are not to be used as a substitute for counseling, psychotherapy, psychoanalysis, mental health care, substance abuse treatment, or other professional advice by legal, medical or other qualified professionals and that it is the Client’s exclusive responsibility to seek such independent professional guidance as needed. If the Client is currently under the care of a mental health professional, it is recommended that the Client promptly inform the mental health care provider of the nature and extent of the Life Doula relationship agreed upon by the Client and Rocksteady Life.
E. The Client understands that in order to enhance the doula relationship, the Client agrees to communicate honestly, be open to feedback and assistance and to create the time and energy to participate fully in the program.
Sally Palmer Rocksteady Life 555 7th Street West, Suite 304 St. Paul, MN 55102
The parties agree to engage in a relationship that can be ended at any time. Rocksteady Life will be available to the Client by text, e-mail and voicemail in between scheduled meetings as defined by Rocksteady Life. All phone calls, video calls and in-person sessions will be charged on a sliding scale fee structure as agreed upon by the two parties. Services may include, but are not limited to diet and nutrition evaluation and guidance, hands-on therapies, lifestyle suggestions, cooking classes, trips to the grocery store of your choice and in-home appointments.
The Client understands that Rocksteady Life neither claims nor implies that any instruction, advice, recommendations, services, or herbal/nutritional products the practitioner provides or recommends will cure, treat, prevent or mitigate any disease condition, but are provided solely for the purpose of nourishing and strengthening the natural function of the various body organs and systems so that they may have a greater capacity to heal themselves. The Client understands that Rocksteady Life believes many diseases are related to unresolved emotional conflicts. The Client understands that counseling or assistance offered in this area is done on a spiritual basis and does not replace licensed psychiatric care or professional counseling. The Client requests the advice and assistance of Rocksteady Life in helping them to learn what they can do to improve their health and fitness. The Client requests this information and any products or services that may attend it as their right to Freedom of Choice in Medicine and Health care retained by them under the Ninth Amendment to the U.S. Constitution, of certain rights, that shall not be construed to deny or disparage others retained by this person.
The time of the sessions and/or location will be determined by Rocksteady Life and Client based on a mutually agreed upon time. The Client will initiate all scheduled calls and will call Rocksteady Life at the following number for all scheduled meetings (651) 560-0878. If Rocksteady Life will be at any other number for a scheduled call, the Client will be notified prior to the scheduled appointment time.
This Life Doula relationship, as well as all information (documented or verbal) that the Client shares with Rocksteady Life as part of this relationship, is bound by the principles of confidentiality set forth in the ICF Code of Ethics. However, please be aware that the Rocksteady Life-Client relationship is not considered a legally confidential relationship (like the medical and legal professions) and thus communications are not subject to the protection of any legally recognized privilege. Rocksteady Life agrees not to disclose any information pertaining to the Client without the Client’s written consent. Rocksteady Life will not disclose the Client’s name as a reference without the Client’s consent.
Confidential Information does not include information that: (a) was in Rocksteady Life’s possession prior to its being furnished by the Client; (b) is generally known to the public or in the Client’s industry; (c) is obtained by Rocksteady Life from a third party, without breach of any obligation to the Client; (d) is independently developed by Rocksteady Life without use of or reference to the Client’s confidential information; or (e) Rocksteady Life is required by statute, lawfully issued subpoena, or by court order to disclose; (f) is disclosed to Rocksteady Life and as a result of such disclosure Rocksteady Life reasonably believes there to be an imminent or likely risk of danger or harm to the Client or others; and (g) involves illegal activity. The Client also acknowledges their continuing obligation to raise any confidentiality questions or concerns with Rocksteady Life in a timely manner.
According to the ethics of our profession, topics may be anonymously and hypothetically shared with other professionals for training, supervision, mentoring, evaluation, and for Life Doula professional development and/or consultation purposes.
5) Cancellation Policy
Client agrees that it is the Client’s responsibility to notify Rocksteady Life 2 hours in advance of the scheduled calls/meetings. Rocksteady Life reserves the right to bill the Client for a missed meeting. Rocksteady Life will attempt in good faith to reschedule the missed meeting.
6) Record Retention Policy
The Client acknowledges that Rocksteady Life has disclosed their record retention policy with respect to documents, information and data acquired or shared during the term of the Rocksteady Life-Client relationship. Such records will be maintained by Rocksteady Life in a format of the Life Doula’s choice (print or digital/electronic) for a period of not less than 2 years.
Either the Client or Rocksteady Life may terminate this Agreement at any time. The client agrees to compensate Rocksteady Life for all doula services rendered through and including the effective date of termination of the Life Doula relationship.
8) Limited Liability
Except as expressly provided in this Agreement, Rocksteady Life makes no guarantees, representations or warranties of any kind or nature, express or implied with respect to the Life Doula services negotiated, agreed upon and rendered. In no event shall Rocksteady Life be liable to the Client for any indirect, consequential or special damages. Notwithstanding any damages that the Client may incur, Rocksteady Life’s entire liability under this Agreement, and the Client’s exclusive remedy, shall be limited to the amount actually paid by the Client to Rocksteady Life under this Agreement for all doula services rendered through and including the termination date.
9) Entire Agreement
This document reflects the entire agreement between Rocksteady Life and the Client, and reflects a complete understanding of the parties with respect to the subject matter. This Agreement supersedes all prior written and oral representations. The Agreement may not be amended, altered or supplemented except in writing signed by both Rocksteady Life and the Client.
10) Dispute Resolution
If a dispute arises out of this Agreement that cannot be resolved by mutual consent, the Client and Rocksteady Life agree to attempt to mediate in good faith for up to 30 days after notice given. If the dispute is not so resolved, and in the event of legal action, the prevailing party shall be entitled to recover attorney’s fees and court costs from the other party.
If any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If the Court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited.
The failure of either party to enforce any provision of this Agreement shall not be construed as a waiver or limitation of that party’s right to subsequently enforce and compel strict compliance with every provision of this Agreement.
13) Applicable Law
This Agreement shall be governed and construed in accordance with the laws of the State of Minnesota , without giving effect to any conflicts of laws provisions.
14) Binding Effect
This Agreement shall be binding upon the parties hereto and their respective successors and permissible assigns.