Healing Hooves Consent Forms

1. INFORMED CONSENT TO TREATMENT:

I (client) freely consents to be a client of Healing Hooves Equine and Animal Assisted Counselling (hereafter called Healing Hooves), Susan McIntosh, Maren McIntosh, Carolyn Miller, Jennifer Eld, Charlotte Manchester, Madison Cruickshank and/or Meghan Vornholt. I recognize that the approach followed with me may include equine facilitated and animal assisted counselling, personal growth and/ or horsemanship, riding or vaulting sessions. I understand that these services and approaches are not an exact science and acknowledge that no guarantees have been or can be made to me about the outcomes of my sessions at Healing Hooves. I understand that I will be invited to be involved in designing and updating my goals. I recognise that the Healing Hooves counsellors, staff, volunteers and contract professionals work as a team and may consult with each other, and/or with other professionals, in order to provide me with the best possible care and services. I consent to be contacted by, and to communicate with, Healing Hooves personnel by phone/ e-mail/ video conferencing and/ or text at the contact numbers and e-mail addresses that I provide. I understand the additional risks this presents, including privacy risks. I confirm I have read, understood and agree to follow the practical and safety protocol, and the risks and conditions of using electronic communications as detailed in this form

2. Payment for Sessions and Cancellation Policy:

• The rate for counselling at Healing Hooves is $210 per hour as of June 1, 2024 and subject to change. Most sessions are 60 or 90 minutes in length. Other sessions, including phone and e-mail consults, are billed according to time spent, in 15 minute increments. The session fee is due in full at or in advance of the time service is provided. We accept cash and cheque, or e-transfer if paid in advance. Our preferred payment method is E-transfer.
• Cancellations with less than 48 hours notice will be subject to a $75 cancellation fee. No shows and cancellations with less than 24 hours notice will be subject to the full session fee.

I have read, understood and agree to comply with the fee schedule and cancellation policy as detailed above:

3. LIABILITY AGREEMENT, RELEASE AND WAIVER

I (client) would like to participate in Susan McIntosh’s and Healing Hooves’ animal assisted and equine facilitated counselling, wellness and horsemanship program. In any activity involving horses, there is always some inherent risk of injury, property damage, and even death. By signing this liability agreement, release and waiver I will be assuming all liability for injury or damage to myself, my child (ren) and/or my property. I acknowledge the risks and potential for risk of horseback riding and being around and interacting with horses and with other animals. However, I feel that the possible benefits to myself/ my child / my ward are greater than the risks assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims against Susan McIntosh, Jeff McIntosh, Maren McIntosh, Catriona McIntosh, Healing Hooves, Carolyn Miller, Jennifer Eld, Charlotte Manchester, Madison Cruickshank and/or Meghan Vornholt. and any staff, volunteers or contracted personnel of these said persons for any and all injuries and/or losses I/ my son/ my daughter/ my ward sustain while participating in any counselling, horsemanship, riding, educational or related activities with Susan McIntosh, Maren McIntosh, Carolyn Miller, Jennifer Eld, Charlotte Manchester, Madison Cruickshank and/or Meghan Vornholt and/or their delegates.

By attending activities at Healing Hooves I agree that I understand the risks of horseback riding and being around and interacting with horses and with other animals and by signing this liability agreement, release and waiver I agree to indemnify and hold harmless the Healing Hooves counsellors, instructors, staff, volunteers, their heirs, successors, administrators, assigns or employees, individually and collectively.

The Client, Participant, and/or the parent/guardians of the minor children, understand the risks of contraction of COVID-19 and/or any other illness, infectious disease or otherwise transmittable diseases. By attending activities at Healing Hooves I confirm that I understand the risks associated with contraction to COVID-19 or other transmittable diseases and by signing this liability agreement, release and waiver I agree to indemnify and hold harmless the Healing Hooves counsellors, instructors, staff, volunteers, their heirs, successors, administrators, assigns or employees, individually and collectively.

4. AUTHORISATION FOR EMERGENCY MEDICAL TREATMENT

In the event emergency medical aid/ treatment is required due to illness or injury during the process of receiving service, or while being on the property of Susan/ Jeff McIntosh, I authorize Susan McIntosh, Maren McIntosh, Carolyn Miller, Jennifer Eld, Charlotte Manchester, Madison Cruickshank and/or Meghan Vornholt. and/or their delegate to:

1. Secure and retain medical treatment and transportation if needed
2. Release records upon request to the authorized individuals or agency involved in the medical emergency treatment.

The authorization includes x-ray, surgery, hospitalization, medication, and any treatment procedure deemed ‘life saving’ by the physician. This provision will only be invoked if the person(s) listed above is unable to be reached.

I authorize Susan McIntosh/ her delegate to administer hand sanitiser, antihistamine, acetaminophen, sunscreen and fly repellant as requested and deemed necessary.

5. Practical and Safety Protocol for Healing Hooves Sessions

The sessions take place at a farm, in part outdoors, with horses and other animals, creating several safety and practical considerations:

1. Dress code: please dress in clothes which you don’t mind getting dirty, and dress for the weather. Wear long pants (no shorts or skirts). Sunscreen recommended for summer sessions. Warm jackets, gloves and hats recommended for spring/ fall/ winter sessions. Footwear: No sandals, open toes/ heels or high heels. Ideal footwear would be boots with a low heel. Avoid jewelry or clothing which may interfere with horse related activities, e.g. large earrings, bracelets, scarves or necklaces.
2. Helmets are mandatory for all horse interactions for clients under 18 and for all clients who get on a horse. If participants ride, the helmet needs to be an approved riding helmet (can be provided by Healing Hooves); for groundwork, a bike or hockey helmet would be adequate.
3. Safety around the horses will be discussed and explored during sessions. All participants are required to follow the safety rules and directions of facilitators and staff while at Healing Hooves. This includes being respectful to the horses, other animals, staff and other participants.
4. Smoking: No smoking at any time (fire risk) anywhere on the premises. Please note this rule also applies to the parent/ other caregiver who brings a child to their session.
5. Cell phones and other electronic devices need to be left in your vehicle/ at home. We are not responsible for any phones or other technology brought onto the property.
6. Medical needs or conditions: Please inform us in writing of any allergies, medications (including side effects), and any medical needs or conditions which might have any impact on your/ your child’s participation in sessions. Consent for medical treatment form, and Consent and liability forms, need to be completed and signed.
7. Please read our payment and cancellation policies carefully and sign to indicate your understanding and agreement.
8. If you arrive early for a session please be aware that we may be busy working with another client in the office, arena or horse pasture. To honour their privacy please wait in your vehicle until we come to greet you. If we are able to start your session early please note that we will also finish the session early, so that you receive the same session length. If you arrive late for your session, we will need to finish at the regular time and bill for the full session time booked. Remember we may have another client booked after you!
9. Please note (and discuss with your child) that while we hope to offer every participant the opportunity to get on a horse during sessions this is not primarily a riding program. Most of the horse interactions will be groundwork i.e. non riding activities and interactions with horses

I have read, understood and agree to comply with the considerations and requirements detailed above:

6. Risks and Conditions of Using Electronic Communication

I, (client) acknowledge that in consenting to having Susan McIntosh, Maren McIntosh, Carolyn Miller, Jennifer Eld, Charlotte Manchester, Madison Cruickshank and/or Meghan Vornholt. and/ or Healing Hooves communicate with and/or provide services through email, internet based services with online discussion posts, social media and video conferencing,

I am aware of the following:

1. Risks of using electronic communication: While the Service Provider will use reasonable means to protect the security and confidentiality of information sent and received using electronic communications, because of the risks outlined below, the Service Provider cannot guarantee the security and confidentiality of electronic communications:

• Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
• Despite reasonable efforts to protect the privacy and security of electronic communication, itis not possible to completely secure the information.
• Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
• Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
• Electronic communications are subject to disruptions beyond the control of the Service Provider that may prevent the Service Provider from being able to provide services
• Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Service Provider or the Client.
• Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
• Electronic communications may be disclosed in accordance with a duty to report or a court order.
• Videoconferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing
• There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized
• Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
• Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

2. Conditions of Using Electronic Communications

• While the Service Provider will endeavour to review electronic communications in a timely manner, the Service Provider cannot provide a timeline as to when communications will be reviewed and responded to. Electronic communications will not and should be used for medical emergencies or other time-sensitive matters.
• Electronic communication may not be an appropriate substitute for some services that the Service Provider offers.
• Electronic communications may be copied or recorded in full or in part and made part of your clinical chart. Other individuals authorized to access your clinical chart, such as staff and billing personnel, may have access to those communications.
• The Service Provider may forward electronic communications to staff and those involved in the delivery and administration of your care. The Service Provider will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.
• Prior to the commencement of the provision of services by the Service Provider through electronic communications, the Service Provider and the Client will establish an emergency protocol to address the following: o Steps to be followed in the event of a technical isSusan that causes a disruption in the services that are being provided by the Service Provider; and o Steps to be followed in the event of a medical emergency that occurs during the provision of services.
• The Service Provider is not responsible for information loss due to technical failures associated with your software or internet service provider.
• The Client will inform the Service Provider of any changes in the Client’s email address, mobile phone number, or other account information necessary to communicate electronically.
• The Client will ensure the Service Provider is aware when they receive an electronic communication from the Service Provider, such as by a reply message or allowing “read receipts” to be sent.
• The Client will take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
• If the Client no longer consents to the use of electronic communications by the Service Provider, then the Client will provide notice of the withdrawal of consent by email or other written communication.

Acknowledgement and Agreement

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described above. I understand and accept the risks outlined above to this consent form, associated with the use of the electronic communications with the Service Provider and the Service Provider’s staff. I consent to the conditions and will follow the instructions outlined above, as well as any other conditions that the Service Provider may impose regarding electronic communications with Clients. I acknowledge and agree to communicate with the Service Provider or the Service Provider’s staff using these electronic communications with a full understanding of the risks in doing so. I confirm that any questions that I had regarding the provision of healthcare services through electronic communications have been answered by the Service Provider.