Regarding Your Participation in Fertility Friday Programs:
Qualifications and Style of Practice
I am a certified Fertility Awareness Educator and Holistic Reproductive Health Practitioner (Justisse College). I have been teaching Fertility Awareness since 2004, and I have personally used the Fertility Awareness Method and charted my own cycles for over 16 years.
My passion, and purpose is working with women in the areas of women’s health, women’s reproductive health, fertility. I strive to honour women’s bodies through my work and help women reconnect with their bodies and their femininity. To that end I regularly seek educational opportunities that enable me to deepen my knowledge in these areas.
I will meet you where you are, with care and respect for your individual needs
without judgement or discrimination. I regard our process as a partnership, in which we reflect together on the purposeful meaning of your concerns and work toward your desired well-being and outcome. I will consign my knowledge and experience to the service of assisting you with your goals. Issues such as how often you see me, topics for discussion, and treatment goals will be tailored to your needs and may differ from other clients.
Consultation & Referral
If you describe symptoms that compromise your well being, and that cannot be addressed through our work together, or are outside of my scope of practice We may refer you for consultation with other mental or physical healthcare providers such as a physician, naturopath, psychologist, psychiatrist, massage therapist, hypnotherapist, etc.
Confidentiality & Records
The privacy of your personal information is an important part of your care. We recognize the importance of protecting your personal information and I am committed to collecting, using, and disclosing your personal information responsibly.
All verbal and written communications between us, in the context of our professional relationship, will be kept strictly confidential. We will not share information concerning you, including the fact that you see me as a healthcare provider, without your written consent, or that of your parent or legal guardian if you are a minor or dependent adult. We will not use information concerning you for purposes of research, teaching, public lecture, or publication without written consent, and without protecting your identity.
Circumstances under which We may be legally obliged to break the confidentiality of our work together, and which may require others to intervene.
1. If you convey information to me indicating that a minor child is subject to abuse, neglect, or other criminal acts. We are required legally to notify the proper authorities.
2. If you place another person at risk of bodily harm, We are required legally to notify the person in question as well as the proper authorities.
3. If you place yourself at risk of bodily harm, We are required legally to take preventive actions as well as notify the proper authorities.
4. If a court subpoenas my records or myself
Under the above circumstances We will ensure that only the required information is released, and that it is released only to authorized persons. We will fully inform you of the release and the reasons for it. Before releasing information, We will attempt to discuss the issues with you, and assist your taking responsibility for reporting yourself (when relevant) and/or for protecting yourself and/or others.
Circumstances under which the confidentially of our work together may be compromised.
1. A 3rd party (e.g. Insurance, Employee Assistance Plan) reimbursing you for fees paid for our work may require a diagnosis and periodic reports.
2. If you convey information to me indicating that a dependent adult or elder is subject to abuse, neglect, or other criminal acts.
3. If you experience a medical emergency, that requires me to share relevant information with your attending physician(s) or other healthcare providers.
4. To communicate with other treating health-care providers
Under these circumstances We will attempt to discuss the issues with you, and help provide you with details of anything I am required to reveal (if permitted) and request your written consent to break confidentiality.
Email Consent
Due to the nature of email communication, there are inherent risks concerning privacy. If you choose to use email communication, you acknowledge the following:
Emails concerning treatment recommendations or suspected diagnoses will be made part of my client records. Certain types of advice and/or support cannot be given over email (medical advice, diagnosis, etc.). Email communication is primarily an opportunity to clarify previous discussed strategies and recommendations, as well as ask questions & receive support between appointments.
By signing the agreement section of this Client Disclosure Form, you have agreed that you have given your informed consent for the collection, use and/or disclosure of your personal information as outlined above.
You have read and understand how my personal information will be used, and the steps being taken to protect my information. You are giving your informed consent to the collection, use, and/or disclosure of your personal information as detailed above.
Cancellation & Refund Policy
If you decide to withdraw from the program within the first 7 days of enrollment, you will receive a refund on the balance of the program (less the prorated amount for the sessions you have attended and the supplies and course materials you have received). There is no refund available on program packages after 7 days. There is no refund available on individual sessions booked outside of a program package.
If you are trying to conceive and become pregnant before our program is complete, congratulations! Please note that there are no refunds on any unused classes or sessions in this situation. If you become pregnant mid program you may wish to save any unused consultations for charting support postpartum.
Missed Appointments
Appointments will take place primarily over Zoom unless otherwise stated. The frequency of appointments is determined by individual need. Sessions range from 60 minutes to 90 minutes in length, and begin promptly at the scheduled time. If you are running late, please notify me in advance. If you need to cancel or reschedule an appointment, I require 24 hours notice except in the case of emergency. If you do not provide me with 24 hours notice of a missed appointment, you will be responsible for the cost of the appointment, and our missed appointment will be counted against the total number of appointments in your package.
You are entitled to a specified number of private consultations during the program you’ve signed up for. You must schedule your private consultation during the specified time frame outlined in the program. If you fail to schedule all sessions within the specified time frame they will expire. You will not be reimbursed for any unused sessions.
Statement Of Responsibility
You acknowledge and agree that Lisa Hendrickson-Jack of Fertility Friday has not represented to you in any way that contracting for her services guarantees that you will not experience an unplanned pregnancy, or that you will experience a planned or desired pregnancy. Accessing services through Fertility Friday does not guarantee that you are healthy or free from any health care risk, that you will or will not be protected in any manner against AIDS or any other sexually transmitted infections, or that you will not suffer injury if you follow the judgment and advice of Lisa Hendrickson-Jack of Fertility Friday during your work together. You further acknowledge Lisa Hendrickson-Jack is not a Doctor, a Naturopath, or a Nutritionist.
You clearly acknowledge and agree that you personally assume all risk and/or legal liability related to your use or implementation of this information. You clearly acknowledge and agree that the accuracy, completeness, usefulness of the fertility awareness method and the application of and reliance on the information you learn throughout any of the Fertility Friday Programs is at your own risk.
Payment Options
Your first payment is due upon signing up for the program, prior to our first meeting. If you are paying in installments a payment plan will be established and each subsequent payment will be deducted in 30 day intervals via PayPal or Stripe.
Statement of Informed Consent
1, I understand that Lisa Hendrickson-Jack is not a Medical Doctor/Naturopath and/or Nutritionist.
2. I understand that any advice and/or recommendations given to me are not mutually exclusive from any other treatment and/or advice from another health care practitioner, now or in the future.
3 I understand that I am at liberty to seek or continue care with any other medical provider that I choose at any point both during and after our work together.
4. I understand that I am free to accept or reject any treatment advice and/or suggestions recommended to me for the duration of this program.
5. I understand that I am encouraged to work jointly and collaboratively with other health professionals as needed at any point during this program.
6. I understand that I am fully responsible for any and all possible risks, injury and complications that may arise from any and all treatments recommended to me for the duration of this program.
7. I understand that participating in Fertility Friday programs in no way guarantees that I will not experience an unplanned pregnancy.
8. I understand that participating in Fertility Friday programs in no way guarantees that I will experience a planned or desired pregnancy.
9. I understand that the services offered by Lisa Hendrickson-Jack are not covered by medical insurance or health insurance providers, and that fees are due prior to our first consultation together, and any subsequent consultations I purchase outside of our initial package/agreement.
10. I understand that 24 hours notice is required for appointment changes or cancellation, and if I miss an appointment without notice I am responsible for the appointment fee. In other words, I understand that if I do not provide 24 hours notice and miss an appointment, my missed appointment will be counted against the total number of appointments in my package.
Agreement
I have read this document and understand its terms. I consent to these practices and policies. I understand that any questions or concerns I have regarding this document or any aspect of this agreement should be directed to: [email protected].
I agree not to distribute the program materials, including giving access to client areas of the website, to anyone else.
I agree to participate fully, and I will ask questions to clarify anything I don’t understand. I am committed to doing everything I need to do to get the results that I want from this program.
