Outdoor Consent Form

Exercise therapy involves the delivery of psychological services outside of the office setting. This may includes walking on public streets, in public parks, or other non-confidential locations.

My Rights

I understand that the laws that protect the privacy and confidentiality of medical information also apply to exercise therapy and that all effort will be made to protect my privacy and confidentiality. However, I also understand that by choosing to conduct my therapy session outdoors, I am allowing for the possibility that these rights may be compromised. I have the right to withhold or withdraw my consent to the use of exercise therapy during the course of my care at any time. I understand that, in this event, Dr. Lager will work with me to find a alternative form of care.

I understand that all rules and regulations which apply to the practice of Psychology in the state of Virginia also apply to exercise therapy.

My Responsibilities

I will inform Dr. Lager if any other person can hear or see any part of our session, or if I have concerns about this, as the session proceeds. Dr. Lager will inform me if she has concerns that any other person can hear or see any part of our session as the session proceeds.

Patient Consent To Services out of the Office

I have read and understand the information provided above regarding psychotherapy outside of the office, have discussed it with Dr. Lager, and all of my questions have been answered to my satisfaction. By signing below, I am waiving my HIPAA privacy rights. I hereby give my informed consent for the use of psychotherapy outside of the office in my care.