Informed Consent & Video Release Form

INFORMED CONSENT:

This informed consent form is required by California Law: SB-577 Health: complementary and alternative health care practitioners.

By entering into any class, training program, or session work you understand:

  • Brian Jansen and others educators at the institute are not licensed physicians

  • The treatments (Polarity Therapy and/or Biodynamic Craniosacral Therapy) are alternative / complementary to healing arts services which are licensed by the State of California.  

  • There is currently no licensure for Polarity Therapy (“Polarity”) or Biodynamic Craniosacral Therapy (“BCST”) in the State of California.  There are however Standards for Practice and a Code of Ethics for practicing and teaching which are maintained by the American Polarity Therapy Association and the Biodynamic Craniosacral Therapy Association of North America. Our instructors adhere to these codes.

  • Brian Jansen’s qualifications include the following credentials (see the “about us” section for qualifications of other instructors):

    • Board Certified Polarity Practitioner (APTA)

    • Registered Polarity Educator (APTA)

    • Approved Training Manager for APP & RPP Polarity Training Programs (APTA)

    • Registered Biodynamic Craniosacral Therapist (BCST/NA)

    • Board Certified Massage Therapist (NCBTMB- not currently offering Massage Therapy services)

    • Certified Trauma Professional:

      • NARM (Neuro Affective Relational Model) Training - for healing developmental trauma

      • Touch Skills for Trauma Therapists (with Kathy Kain, PhD)

Theory of Treatment & Nature of Services

The Polarity Therapy Institute’s Training Programs and Classes offer students a theoretical model for understanding and working therapeutically with the Human Energy Field. This is a holistic model for health that supports energy balancing and embodied consciousness as a pathway toward physical, mental and emotional wellness. Interventions used in this system include:

  • Manual interventions such as touch-therapy and physical contact with the body to support energy movement and balancing

  • Verbal interaction which may include guided meditation and somatic exploration (using one’s awareness to bring attention to one’s internal experience of the physical body), inquiry into the client’s overall experience, sensation and perceptions, verbal exercises and dialogue that support an awareness of energy dynamics and encourage energy balance

  • Physical movement and movement education, stretching and exercises; which are not intended to be strenuous

  • Client education concerning diet and nutrition from an energetic perspective.

It should be understood this system is complementary healthcare. It is not a replacement for medical care, psychotherapy or psychiatry, physical therapy or massage, yoga instruction, work with a nutritionist or dietician, or any other form of licensed healthcare. If the participant or their clients have any health concerns they should consult an appropriate licensed healthcare provider and cease participation in class.

While the theoretical approach taught in Polarity Therapy offers a useful framework which can support practitioners from various clinical disciplines, all participants in the Polarity Therapy Training/ Classes should clarify to what extent using the Polarity approach in their practices is condoned by the law in their area, and/or the licensing body for professions to which they belong.

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. They are required to act in the “practitioner” role if they intend to receive a certificate of completion.

Concerning Touch-Therapy

A key part of Polarity Therapy training involves touch. By entering into this agreement, the student agrees to receive touch-therapy as part of the live training whenever in the “client” role. Experiencing the work in the client role is an important part of developing as a Practitioner. The student may withdraw consent to receive touch at any time by verbally alerting whoever is in the “practitioner” role.

The client remains clothed during the touch therapy. The touch therapy is intended to feel safe, comfortable, non-invasive, and non-aggressive at all times, without any sensual, erotic or sexual undertones. If at any point the touch is felt as uncomfortable or aggressive or in any way unsafe, the client has the right and is encouraged to speak up, stop the session, and alert the instructor and the practitioner so that adjustments may be made. When acting in practitioner role, students are required to honor the boundaries and needs of the test clients they are working with to insure safety and comfort.

Legal Regulation & Limitation of Liability

Legal regulation of Polarity Therapy varies state to state. If you are practicing in California the practice is governed by SB-577 Health: complementary and alternative health care practitioners. Please check with the law in your particular area about what is required to practice legally.

Regardless of what style of healthcare you practice you should work within the scope of your practice and your scope of expertise as determined by the type of license you have, your education and clinical experience.  The Polarity Therapy training is not intended to replace any other professional training. For example it is not a replacement for a massage, psychotherapy, or medical education. The Polarity Therapy Training provides adjunctive skills for those already within a therapeutic profession; it is used by psychotherapists, massage therapists, yoga teachers, nutritionists, doctors, nurses, acupuncturists, and many other health professionals. The complete Board Certified Polarity Practitioner training (800 hours) is the only level of training endorsed by the American Polarity Therapy Association for an independent Polarity Practitioner who is not operating under another healthcare license; the International Polarity Education Alliance offers the Polarity Therapy Practitioner (PTP) designation to persons and does not require someone to hold another professional license.

The Polarity Therapy Institute offers a Certificate of Completion to those that complete the Beginner (Associate) and Advanced (Registered) Levels of training.  Additional application is required to APTA or IPEA to use their credentials. Our Certificate of Completion refers only to completion of the modules / program noted, and the associated training requirements.  How you apply the learning and experience from the Polarity training to your own practice depends on your own education and training, licensure and scope of practice for your discipline.  Any questions about this should be directed to your professional association, licensing board or relevant legal, ethical or clinical resources for your professional discipline.  Polarity Therapy Institute Faculty and Staff are in no way responsible for your application of Polarity theory and skills, and will not be liable for any legal or ethical issues regarding your use of Polarity Therapy.

Self-Care

If you are accepted and agree to enroll in the Polarity Therapy Training or Classes, you are acknowledging that the therapy can involve personal develipment and that you are responsible for assuring that you have the resources for appropriate self-care.  The Polarity Therapy Institute Instructor and Assistants are available to assist if difficult emotional themes emerge, but participants are responsible for managing their own personal well-being.  It is important to remember that this is a practitioner training program and not group therapy or a self-help workshop.

All sessions that you receive from the Polarity Faculty and Teaching Team while in training are provided under the framework of supporting your learning; they are not a replacement for more extended therapeutic care from a Board Certified Polarity Practitioner or other provider outside class. If you require medical, psychological or physical support it is your responsibility to seek those resources. 

Please remember the training is intended to support the student-practitioner’s development, rather than the personal healing process of the person in the “client” role. One’s process may be truncated, interrupted for teaching points, and one’s personal needs may not be attended to as they would in normal session work. Each participant is encouraged to receive their own private sessions and draw upon their resources for self-care should any challenges arise during the training. Participation in the “client” role is always voluntary.

If you have any questions about the appropriateness for you of participating in this training, either for your clinical practice of your personal development, please direct them to the Polarity Therapy Institute at

polaritytherapyinstitute@gmail.com

VIDEO RELEASE:

All online and in person classes are recorded, and may be used in a variety of ways in the future for educational, marketing or other purposes. By enrolling in any class or training you enter into the following agreement with Polarity Therapy Institute:

  • 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 & Jansen Wellness, its assigns, and/or any person or entity authorized by the Polarity Therapy Institute, 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 & Jansen Wellness may elect.

  • I understand the Polarity Therapy Institute and Jansen Wellness owns and retains 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 Jansen Wellness, its 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 Jansen Wellness 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 Polarity Practitioner Trainings and Classes.

  • I grant the Polarity Therapy Institute and Jansen Wellness 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 of 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 Jansen Wellness may approve in its 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. My electronic signature on the enrollment documentation reaffirms that I grant this unconditional release. Many demonstrations are recorded on video; If I volunteer to participate in a demonstration, my digital signature below reaffirms 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 and by enrolling I affirm that I fully understand the content, meaning and impact of this release and agree to all that is stated above.