Handouts

Ayurveda & Yoga Therapy Client Consent Form


Yoga and Ayurveda are practically and philosophically closely linked.  While the emphasis of yoga is spiritual, many people seeking greater physical and emotional health have used these practices in a nonsectarian manner and have found them to be beneficial and effective. Ayurveda is a system of balance that utilizes knowledge of the fundamental energies of the body and of substances in nature to help maintain balance and optimize functioning, and Yoga is one of many tools within Ayurveda. Yoga is generally recommended as part of an Ayurvedic protocol.

Ayurveda and Yoga are holistic in asserting that true healing must occur on all levels of being: physical, energetic, emotional, mental, and spiritual.   The healing modalities used are complementary to western medicine, and as such should not be construed as a substitute for either a medical diagnosis or the services of a physician.  Laurene Hayden is trained in yoga traditions and techniques and in Ayurvedic Yoga Therapy, and is a certified NAMA approved Ayurvedic Health Practitioner.  I understand that she is not a medical doctor, nor a licensed counselor or nutritionist, and that neither Ayurvedic consultation nor yoga therapy are licensed by the State of Arizona.

During treatment, a specific therapeutic program will be individually designed for each client, with client input, participation, and consent.  Therapeutic recommendations and practices are based on Ayurvedic and yogic theory, and can include lifestyle and dietary/herbal recommendations, yoga postures, breathing practices, meditation, yogic massage, journaling, etc.  None of these recommendations are a substitute for the advice of a physician.  It is not within the scope of these services, nor have any claims been made to me, for Laurene Hayden to assume responsibility for the treatment of specific health problems or for the diagnosis, treatment, or cure of any particular health problem.

 I understand that any herbal food supplements recommended for me are not drugs and do not treat any disease. I further understand that any herbs recommended have the potential to interfere with the actions of prescription medications, and that I should consult my physician before undertaking any herbal supplements if I am also taking medications.  Any other programs recommended also do not treat any disease, but are alternative approaches which are for the purpose of specifically balancing the doshas, or underlying energetic components of the physiology, for the purpose of creating balance in the physiology and improving overall mental and physical well-being.

 I will not modify or suspend any treatment program given to me by my physician or healthcare provider based on the recommendations I receive during my consultation, and I understand that I should consult my physician or other licensed healthcare professional if I have any concerns whatever regarding my ability to perform the yoga postures and techniques, and for the suitability of any suggested dietary or supplemental changes which I may be considering. I understand that I should advise my Therapist-Practitioner if there is anything I am not comfortable doing or which is painful for me to do, or if I have any concerns whatsoever. I acknowledge that I am seeking consultation of my own choice, without coercion, and it is my role to decide and perform only those movements, recommendations, and techniques, that I deem safe and supportive for my health on each occasion of yoga practice and application of Ayurvedic techniques.

 I understand that all information shared is strictly confidential, with the exceptions of permission given to share with other professionals, with persons close to me, or as required by the Privacy & Confidentiality  Laws of the State of Arizona.

 All fees are due in full before or at the time services are rendered.  The fees paid herewith are non-refundable and non-transferable.  Cancellations made less than 48 hours in advance are subject to fees at the full rate.

I have read and understood the above.

 

___________________________            _____________________________

Print name                                                                Sign and Date