Informed Consent Form

Please print a copy of this form for your records as if forms part of our working contract for services provided. The contents of the intake form including instructions also act as part of our contract.

**Compliance with California Law:**

This consent form is in accordance with California Law: SB-577 Health: complementary and alternative health care practitioners.

**Understanding of Practice:**

By entering into this practice, class, or training program with Brian Jansen, CTP, BCPP, RCST, you understand:

- Brian Jansen is not a licensed physician or psychotherapist.

- The treatment (Polarity Therapy and/or Biodynamic Craniosacral Therapy) is alternative/complementary to healing arts services licensed by the State of California.

- There is currently no licensure for Polarity Therapy or Biodynamic Craniosacral Therapy in the State of California. Brian Jansen's work adheres to the Standards for Practice and Code of Ethics maintained by the American Polarity Therapy Association and the Biodynamic Craniosacral Therapy Association of North America.

**Theory of Treatment:**

This holistic practice is based on a comprehensive model of wellness that encourages harmony in physical, mental, emotional, and spiritual aspects of health. It is centered around building health and vitality, and facilitating the body/mind’s intrinsic capacity for self-regulation and self-healing, rather than targeting specific diseases or disorders. The client’s own agency and participation in their health-building process is a key factor in the success of these therapies. These services are provided from a trauma-informed perspective, acknowledging how trauma impacts the whole person and seeking to restore the body-mind system’s inherent capacity for health after trauma.

**Nature of Services:**

The practice includes both in-person and remote (Zoom) sessions, tailored to the client’s needs and comfort. Sessions begin with an inquiry into the client's intentions and wellness goals in body, mind, and spirit. This is followed by supportive attention to the body-mind system through listening and dialogue, presence, curiosity, focusing on internal experiences and shifts in energy, and during in person sessions, therapeutic touch. For remote sessions, guidance for self-directed touch is provided. Attention to diet, movement, and lifestyle choices is integral to the holistic health journey and may be discussed as part of the work together depending on the client’s goals.

Concerning Touch:

The nature of therapeutic touch in this practice differs from other kinds of manual therapy like massage or physical therapy. The client remains clothed throughout the session and all touch is intended as non-sensual and non-aggressive. It is another form of listening to and unlocking the inherent health and energy in the body-mind system. The practitioner follows protocols to insure the client’s safety and wellbeing so the touch is not directed by the client’s whims or requests as it might in a massage. If the client is uncomfortable at any point for any reason in the process, the practitioner should be alerted to make adjustments. Consent to receive touch can be withdrawn at an any time.

**Practitioner’s Qualifications:**

- Certified Trauma Professional (CTP)

- Board Certified Polarity Practitioner (APTA)

- Registered Polarity Educator (APTA)

- Approved Polarity Therapy Training Manager (APTA)

- Registered Biodynamic Craniosacral Therapist (BCST/NA)

- NARM Training

- Somatic Practice Training (with Kathy Kain, PhD)

- Neuro Affective Touch Training

- Board Certified Massage & Bodywork Therapist (NCBTMB) - not currently offering massage

Payment Policy:

Payment is required prior to or at the start of the session.

Insurance Policy:

Services are not billable to insurance. Receipts can be provided, but insurance companies typically do not reimburse these services. Diagnostic codes are not provided.

CANCELLATION & RESCHEDULING POLICY

Notice Requirements: Cancellations or reschedules with more than 48 hours’ notice incur no charge. Cancellations or reschedules with less than 48 hours’ notice will be charged the full session fee, payable at the time of cancellation. No-shows also incur the full session fee.

Preferred Notice: Whenever possible, I appreciate more than 48 hours’ notice if you need to cancel or reschedule. If an in-person session is not feasible, an online session is always an option.

Late Payments: Outstanding balances must be settled promptly. Past-due payments may be referred to a collections agency.

Provider Cancellations: Occasionally, I may need to reschedule due to my teaching commitments. If this occurs, I will notify you in advance and make every effort to find a time close to your regular appointment.

ONGOING APPOINTMENT POLICY

Consistency in Scheduling: After up to three initial sessions, clients are asked to establish a regular appointment schedule—weekly, biweekly, or every four weeks. I do not currently offer sessions on an as-needed basis (i.e., random scheduling times) except during the initial trial period for up to three sessions. After this period, I only see clients who are able to commit to a regular schedule of sessions.

Rescheduling Needs: To maintain the integrity of your care, if you cancel an appointment, I ask that you reschedule within the same time period (e.g., for a biweekly schedule, within two weeks). This helps ensure continuity and honors the agreed-upon frequency of sessions.

Frequent Changes: If cancellations or reschedules become frequent, we may need to adjust your appointment frequency or discuss the possibility of releasing your regular time slot. Before making changes, we can explore scheduling alternatives to see what best supports your needs.

Scheduling as a Reflection of Progress

Frequent cancellations can sometimes signal deeper dynamics at play in our work. It’s not uncommon for resistance or avoidance to arise when someone is on the verge of a significant breakthrough, as the mind and body may instinctively cling to familiar patterns. Other times, a shift in care may be needed. If you find yourself needing to reschedule often, we can take some time to explore whether something deeper may be coming up in our work, whether a different approach might be more supportive, or if additional resources could be helpful.

Debt Collection Policy:

Accounts unpaid/past due for more than 14 days will be subject to debt collection, including additional fees (typically around $160 on top of the $200 session fee).

Confidentiality Policy:

All sessions are confidential, except as required by law or in cases where the client poses a threat to themselves or others.

Working with Minors Policy:

Sessions for minors are confidential, with necessary disclosures to guardians only in specific health or legal situations. Guardian consent is required.

Educational Classes & Workshops

Classes provide a theoretical model of holistic health which may be useful to individuals in a self-healing process, or to practitioners and therapists seeking an integrative approach to wellness. While the theoretical approach taught offers a useful framework which can support practitioners from various clinical disciplines, all participants in the classes and trainings should clarify to what extent using the approach in their practices is condoned by the law in their area, and/or the licensing body for professions to which they belong. Brian Jansen assumes no legal liability for the individual’s participation in classes or execution of materials learned in a professional setting.

The training and classes may involve any or all of the interventions described above which the student may experience as a “test client.” Students are not required to act in the “client role” if for any reason they are uncomfortable doing so.

Video Release / Waiver (for Classes & Trainings ONLY)

By attending any class or training, you enter into the following agreement with Brian Jansen and/or the Polarity Therapy Institute concerning the recording of classes.

  • I have been informed that training both in live classes and online web conferences / classes may be recorded and that my name, likeness, image, voice, appearance, and /or performance may be captured as part of the sessions in which I participate.

  • I hereby grant permission to Polarity Therapy Institute & Brian Jansen, their assigns, and/or any person or entity authorized by these parties, to use these recordings in any format, without limitation, and the right to edit, duplicate and to use these recordings in whole or part, as the Polarity Therapy Institute & Brian Jansen may elect.

  • I understand the Polarity Therapy Institute and Brian Jansen own and retain the copyright interests to these recordings. I hereby waive all rights and interest in the results and proceeds of the video or audio recordings produced in these trainings/ classes/ events in which I participate, as well as the right to inspect, modify, or approve it. I hereby forever waive any right to royalties, payment, or compensation hereunder beyond the consideration stated herein.

  • I hereby release, defend, and hold harmless the Polarity Therapy Institute and Brian Jansen, their officers, agents, licensees and assigns, from and against any claims, damages or liability arising from or related to my appearance in training or educational videos. I grant the Polarity Therapy Institute and/or Brian Jansen the right to present, market and otherwise distribute these recordings in whole or part, for educational, training, research or marketing purposes, including the right to use these recordings for publicizing or promoting future Practitioner Trainings and Wellness Classes.

  • I grant the Polarity Therapy Institute and Brian Jansen the exclusive worldwide right in perpetuity to use any or all of the video recorded during its live trainings/ events and online events/classes/workshops including but not limited to the right to prepare derivative works therefrom, lease, license, convey or otherwise use or dispose fo the Images, Audio, or Video by any method or through any medium now or hereafter known, in any field of use, to permit the duplication, distribution and public display thereof, all upon such terms and conditions as the Polarity Therapy Institute and Brian Jansen may approve in their sole discretion.

  • I understand that if I ask questions while a recording is in progress I will be recorded and will appear in the video/audio recording. I affirm that I grant this unconditional release. Many demonstrations are recorded on video; If I volunteer to participate in a demonstration, I reaffirm my unconditional release. I am over the age of 18 years and have the right to enter into this agreement and do so willingly and freely. I have read this release before enrolling in any class or training, and fully understand the content, meaning and impact of this release and agree to all that is stated above.