Bethell Hospice Consent Form for Complementary Therapy Services

Bethell Hospice requires consent for any in-person complementary therapy services provided in the house, in addition to the In-Home volunteer visiting services. Please review the following information and sign in the space provided.

Complementary Therapy programs are used to supplement conventional health care practices. These programs are designed to provide additional support to promote self-care, relaxation, improved sleep, reduce muscle tension, and promote physical and emotional comfort and balance. In respect to complementary therapy, ‘healing’ does not mean cure, it promotes balance and wellness within the mind and body. ALL complementary therapy sessions are provided by trained volunteers.

GENTLE AROMA TOUCH

Gentle Aroma Touch is the application of a delicate, smooth, and methodical touch and motion from the Complementary Therapy Volunteer’s hands involving feather like gentle touches and/or stroking along specific areas of the lower arms and hands, and the lower legs and feet. Diluted essential oils or fragrance-free grapeseed oils will be applied. Participants have the option of lying down or being seated in a chair. You are required to inform your volunteer about all allergies and skin sensitivities, and particularly about any allergies to grapeseed oil or any essential oil.

THERAPEUTIC TOUCH

Therapeutic Touch is also an energy-based holistic therapy technique used to help balance one’s energy levels. The Complementary Therapy Volunteer consciously directs the process of energy exchange through a sequence of gentle hand movements over the individual’s body, in their energy field. By using their hands as a focus for energy healing this sequence may be applied by a light touch or without touch as the individual rests in a sitting or lying position.

CONSENT AND AGREEMENT

I understand that:

* Complementary Therapy is not a medical treatment and is not a substitute for any professional medical advice, treatment or intervention.

* Complementary Therapy appointment sessions are approx. 20 minutes long.

* Complementary Therapy is to promote comfort, relaxation, peacefulness, and a sense of wellbeing.

* Complementary Therapy sessions will be administered by a Complementary Therapy Volunteer of The Bethell Hospice trained in the chosen Complementary Therapy and will be given only with my consent.

* I agree that The Bethell Hospice, its staff, and the Complementary Therapy Volunteer will not be liable for the result of a Complementary Therapy session. I indemnify and release them from all liability which may arise from such a session.

Select one of the following boxes:

RESIDENT (please provide name of individual receiving complementary therapy)

CLIENT (please provide name of individual receiving complementary therapy)

Power of Attorney (please provide name of individual receiving complementary therapy)

Substitute Decision Maker (please provide name of individual receiving complementary therapy)

Resident Name

Client Name

Power of Attorney Name / On Behalf Of

Substitute Decision Maker Name / On Behalf Of

I have been informed of the nature of the chosen Complementary Therapy and have read and understand the above information and consent to receive this therapy.

Name *

Dated *

Please forward a copy of this completed form to the following email address for my records: *

Messages sent via the internet can be intercepted. If you are concerned about providing your personal information by email or website form submission, please contact us directly at 905-838-3534 to arrange for an alternate method of communication.

For more information, please refer to our Bethell Hospice Privacy Statement.

Consent Form for Complementary Therapy Services

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