Page 1 of 5 Marley s Mission Consumer Consent, Rights and Responsibilities (Form #4 7/2013) CONSUMER CONSENT, RIGHTS AND RESPONSIBILITIES The following is to inform you of the policies and therapeutic practices of Marley s Mission Incorporated. This statement is intended to convey pertinent information regarding services, allowing you to make choices based on correct information. Please read this information carefully. If you have any questions, please feel free to discuss them with your therapist. SECTION 1: DESCRIPTION OF THERAPY SERVICES PROVIDED Marley s Mission Incorporated is a non-profit organization which provides Equine Assisted-Psychotherapy (EAP) and Equine-Assisted Learning (EAL) free of charge to children and youth who are survivors of trauma. EAP and EAL utilizes a team approach to counseling with a mental health professional, a horse professional, and one or more horses to address treatment goals. This type of psychotherapy utilizes an experiential modality to foster emotional growth and learning, which means that clients learn about themselves and others by participating in activities with the horses, and then processing (or discussing) feelings, thoughts, beliefs, behaviors, and patterns. EAP and EAL activities are designed to best create metaphors to real life, as everything done with the horses can be related to what is happening in the client s daily life at home, school, work, in relationships, etc. Through an experiential learning process, the client is actively engaged in taking initiative, making decisions, experimenting, problem solving, constructing meaning, being creative, assuming responsibility, and being accountable for results. While experiential approaches can be conducted in a variety of settings, EAP and EAL has the added advantage of utilizing dynamic and powerful living beings which enhances the experiential process. EAP and EAL does not provide lessons in horsemanship nor does it involve any mounted activities for the safety of the client. SECTION 2: TEAM APPROACH TO TREATMENT EAP and EAL utilizes a team approach to treatment. Both an Equine Specialist (ES) and a Mental Health Professional (MHP) co-facilitate psychotherapy sessions with the horses and clients. Responsibilities of the ES include: facilitating the structured horse-assisted activities, keeping sessions focused on the horses behaviors, emotions, and nonverbal cues, and noticing changes in the horses behavior and adapting appropriately to maintain the physical safety of the client. Responsibilities of the MHP include: developing an individualized treatment plan with the client and his or her parents/guardians, ensuring that interventions relate to the agreed upon treatment plan, monitoring the client s therapeutic progress, and focusing on verbal and nonverbal communication from the client in order to maintain his or her emotional safety.
Page 2 of 5 Marley s Mission Consumer Consent, Rights and Responsibilities (Form #4 7/2013) SECTION 3: RISKS AND BENEFITS OF EQUINE ASSISTED PSYCHOTHERAPY EAP and EAL is a modality of psychotherapy that utilizes horses to assist in emotional growth and learning, providing unique therapeutic benefits, including, but not limited to the following: 1. Due to the naturally intimidating size and power of the horse, working with horses creates a natural opportunity for overcoming fear and developing confidence. When a client is able to accomplish a task involving the horse, in spite of those fears, he or she can develop confidence and self-assuredness that can be transferred to other intimidating and challenging situations in life. 2. Horses are very much like humans in that they are social animals, possessing distinct personalities, attitudes, and moods. While an approach may work with one horse, it won t necessarily work with another. Thus, it requires the client to engage in a variety of ways, just as they must with other people. In other words, horses provide vast opportunities for metaphorical learning. 3. Horses possess an acute sensitivity to nonverbal communication and respond to the messages clients give them in the moment. These responses give the client and the treatment team information that can facilitate awareness of current patterns and motivate change to new ones. Through the equine contact and activities, clients learn that if they change their own behaviors and ways of relating, the horse responds differently, which of course, provides a very valuable lesson that can be used throughout one s lifetime. While there are significant benefits to be obtained from this type of psychotherapy, there is also some amount of risk involved. As is the case in any psychotherapy, therapeutic success depends in large part on the client s desire for change and willingness to be honest with both him/herself and the treatment providers. However, as the client becomes comfortable with his/her providers, he/she may begin to share sensitive information that can be painful to talk about. Ultimately, dealing with difficult feelings in psychotherapy is necessary for growth, but there is some inherent discomfort involved in dealing with difficult feelings as well as in making change. The utilization of horses in the psychotherapeutic space also poses additional risks to the physical safety of the client, and such risks can be found in SECTION 4. SECTION 4: EXPLANATION OF INHERENT PHYSICAL RISKS WHEN WORKING WITH HORSES Participating in activities with horses involves a degree of risk that may result in accident or injury. Horses are herd animals that, in the wild, are preyed upon by other predatory animals. As a result, they have to look after themselves when they are frightened by sudden noises or movements that they perceive as threatening and they do so by running away or potentially becoming aggressive. It is important that the client is aware of these responses when working with horses. While the Mental Health Professional (MHP) and Equine Specialist (ES) will do all they can to reduce the risk of injury, clients and parents/guardians are asked to take responsibility for themselves at all times by being aware of the horses and their movements around the arena and to act in a manner as to keep oneself safe when necessary. The ES and MHP will intervene during a session if they believe that the client(s) or the horses are at risk and clients are required to comply with provider instruction. SECTION 5: RELEASE OF INFORMATION FOR CONSULTATION/COORDINATION OF SERVICES The Marley s Mission Incorporated staff is comprised of contracted independent consultants who have had unique and varying individual training experiences. Thus, each individual provider will be consulting with the Trauma Therapy Coordinator for Marley s Mission Incorporated, regarding all services being provided.
Page 3 of 5 Marley s Mission Consumer Consent, Rights and Responsibilities (Form #4 7/2013) Treatment providers may also need to discuss confidential material with the Program Director for the purposes of coordination of services. By signing this consent, you agree to the release of confidential information for the purposes of consultation/coordination of services to the Trauma Therapy Coordinator and the Program Director of Marley s Mission Incorporated. SECTION 6: STATEMENT OF CONFIDENTIALITY AND LIMITATIONS TO CONFIDENTIALITY Content obtained from the client in psychotherapy sessions will be handled professionally and confidentially. This information will be used by the Mental Health Professional (MHP), the Equine Specialist (ES), the Trauma Therapy Coordinator, and the Program Director for your therapeutic benefit. If for treatment purposes, we need information from another party, we will ask you to sign a release of information. Due to the unique nature of the population served at Marley s Mission Incorporated, it is important to note specific limits to confidentiality in relation to child abuse, in which the Marley s Mission Incorporated treatment providers are required by law to report information to Childline. Any abuse disclosed by the client or parent/guardian(s) about any child, regarding physical abuse, sexual abuse, verbal and/or emotional abuse or neglect must be reported by treatment providers to Childline. Due to the nature of our referral process, abuse may have already been reported to authorities; however, the only time that Marley s Mission Incorporated treatment providers would not re-report an incident that is disclosed is if a detailed documentation of the abuse report filed with the report number is provided to Marley s Mission Incorporated and a copy of the report is given to the treatment team to be retained in the client s file at Marley s Mission Incorporated. In the event that your child discloses a new abuse incident to his or her treatment team providers, the Marley s Mission Incorporated Professional staff will make every effort to contact you, the child s parent/guardian, prior to filing a report with Childline. However, if the treatment providers are unable to reach the parent/guardian after multiple attempts at contact, the provider would have to file a report with Childline within 24 hours of the disclosure in accordance with Pennsylvania State Law. Please refer to SECTION 7 for additional information regarding additional requirements [other than child abuse] for mandated reporting. SECTION 7: CLIENT EXPECTATIONS/RIGHTS As a consumer of or parent/guardian of a consumer of EAP and/or EAL as provided by Marley s Mission Incorporated, I am provided the following rights: 1. The right to competent, considerate, and respectful care without discrimination on the basis of race, color, religion, creed, national origin, gender, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. 2. The right to a complete description and explanation of my child s treatment including diagnosis and purpose and to receive a formal individualized treatment/services plan developed with my input. 3. The right to review treatment, transfer, or discharge plans with professional staff/treatment team, or appoint a representative to do so.
Page 4 of 5 Marley s Mission Consumer Consent, Rights and Responsibilities (Form #4 7/2013) 4. The right to confidentiality whereby information revealed by me or my child during treatment will be kept strictly confidential and will not be revealed to anyone other than treatment team members without my written permission. The law provides for the following exceptions to this provision: a. If the clinician has knowledge of child, disabled, or elder abuse b. If the clinician has knowledge of the consumer s intent to harm him/herself or others c. If the clinician receives a court order to the contrary d. If the consumer enters into litigation against Marley s Mission Incorporated e. If medical emergency necessitates disclosure SECTION 8: PROVIDER EXPECTATIONS AND REQUIREMENTS OF THE CONSUMER I understand that it is my responsibility to notify both the Program Director and the Mental Health Professional(s) by telephone should I need to cancel an appointment. Notification of cancellation should be given at least twenty-four (24) hours prior to the scheduled appointment time. I understand that after three (3) No Call-No Shows and/or Late Cancellations (viz., cancellations without giving twenty-four (24) hours notice) my and/or my child s services at Marley s Mission will be terminated. I understand that if I bring my child to Marley s Mission without proper attire and/or safe footwear, my child will not be able to participate in his or her session and the session will count as one (1) Late Cancellation. SECTION 9: TREATMENT PLAN Each client will have an individualized treatment plan that will guide therapeutic activities occurring in EAP and/or EAL sessions. EAP and EAL sessions are structured and facilitated to deliberately address the reasons clients sought therapy services. Thus, the treatment plan will consist of goals that have been agreed upon by the client, his or her parent/guardian(s), and the Mental Health Professional who will be providing services. Such goals will be shared with the Equine Specialist who will be co-facilitating the client s EAP and/or EAL sessions. Treatment plan goals and progress toward such goals will be re-evaluated as necessary and any pertinent additions and/or changes to the treatment plan will be made for the purpose of furthering therapeutic gain. SECTION 10: TERMINATION OF SERVICES If at any time the Marley s Mission Incorporated treatment team working with you and/or your child feels that the child is not receiving sufficient therapeutic gain from the services being provided, team members will discuss concerns with the parent/guardian(s) to determine if continuation of EAP and/or EAL services at Marley s Mission Incorporated are still indicated. If treatment providers feel that the child would benefit from either additional psychotherapy services and/or services in lieu of EAL and EAP, they will inform the client s parent/guardian(s) of such recommendations in a timely fashion. If the Marley s Mission Incorporated treatment team members, the parent/guardian(s) of the child, and the child agree that treatment plan goals have been met and that no additional treatment plan goals could be reached via EAP and/or EAL, then arrangements for termination of therapeutic services at Marley s Mission Incorporated will be made. Termination of any psychotherapy is a process. The child participating in these services will have developed strong relationships with both the treatment team providers and horses alike. It is important that a specific date of termination/final EAP and/or EAL session is set in advance to insure appropriate termination of
Page 5 of 5 Marley s Mission Consumer Consent, Rights and Responsibilities (Form #4 7/2013) treatment that will allow the child to process his or feelings regarding separation from the agency and to retain as much of the therapeutic gain as possible. Additionally, if the parent/guardian(s) decides to terminate treatment for his or her child, he or she must contact Marley s Mission Incorporated to inform the child s treatment team providers. When at all possible, it is strongly recommended that the parent/guardian(s) return with the child for at least one final session in order to facilitate an appropriate termination of treatment services. CONSENT FOR TREATMENT AND WAIVER OF LIABILITY I,, hereby consent to my child, receiving Equine-Assisted Psychotherapy (EAP) and/or Equine-Assisted Learning (EAL) as provided by Marley s Mission Incorporated. I acknowledge that the scope of EAP and EAL, including the potential for injury which can occur from working with horses, caring for horses, or being involved in therapeutic activities that include horses has been fully explained to me by the Marley s Mission Incorporated staff. Because of the potential benefits of the EAP and EAL treatment, I hereby agree to hold harmless and indemnify Marley s Mission Incorporated and its treatment providers, and further release them from any liability or responsibility for accident, damage, injury or illness to me or my child or to any family member or spectator accompanying the undersigned and his/her child on the premises, unless caused by the willful misconduct or gross negligence of my child s treatment team. The individual treatment team that will provide EAP and/or EAL for my child is comprised of: (MHP) and (ES) Client Signature (if age 14 or older) Parent/Guardian Signature Provider Signature