Consent Form
Adult
Patient Name: ______________________________________
Date: ___________________________
Prior to assessment/treatment, you as the patient must supply your informed consent. Informed consent means that
you as the patient need to be given adequate explanation about the proposed assessment/treatment to allow you to
make an informed decision about whether or not to proceed with the proposed assessment/treatment. Adequate
explanation about the proposed assessment/ treatment would include the anticipated outcome, possible alternatives
to, and possible risks associated with the proposed assessment/treatment. Further, you must have the capacity to
provide consent, which in Saskatchewan requires that you are age 16 or over. A patient under the age of 16 or a
patient who does not demonstrate capacity to consent requires parental/ guardian presence during assessment/
treatment and parental/ guardian consent to access assessment/treatment.
In regards to Initial Assessment:
Purpose, Anticipated Outcome, and Alternatives:
- use ISM to catalogue your “shifts” from head to toe in the default standing position
- find the “driver” for your “meaningful task”
- discuss findings and proposed treatment plan, as well as other conservative options for care
Risks include but are not limited to:
- dizziness, feeling “woozy”, or generally unwell
- increased soreness following your assessment in current symptom areas
- “waking up” old injured areas
- creating new symptom areas
In regards to Treatment:
Purpose, Anticipated Outcome, and Alternatives:
- use ISM principles of “RACM” or Release, Align, Connect and Move at the current driver’s “impairments” for a
“meaningful task”
- “RA” may be satisfied with any of tape, release techniques, mobilization, awareness exercises, use of belts/ braces,
and/or use of awareness cues
- “CM” may be satisfied with any of awareness cues, brain training, core exercises and/or optimal movement training
made progressively more challenging, functional, and specific to your goals
- goal is to resolve the current “driver” for your “meaningful task” to its fullest potential which may promote improved
symptoms and/or function in your “meaningful task”
- unwind your body’s “snowball effect” or “onion layers” and promote holistic alignment
- continually revisit your goals as each meaningful task may have a different “driver”
- supply you with tools for at home whether they be awareness exercises, sling stretches, decompression exercises,
and/or brain training exercises to promote self maintenance and resolution of the driver to its fullest potential
Risks include but are not limited to:
- dizziness, feeling “woozy”, or generally unwell
- increased soreness following your assessment in current symptom areas
- “waking up” old injured areas
- creating new symptom areas
- skin reactions including, but not limited to, rashes, irritation and blistering particularly if tape and/or release
techniques such as frictioning are agreed upon as a treatment interventions
Consent can be withdrawn at any time. Raise any questions you have pertaining to assessment or treatment,
at any time, and your questions will be addressed.
------------------------------------------------------------------------------------------------------------------------------------------I, _____________________________________________________, on this date of ______________________________________________
give my express consent to be assessed by Lynne Brochu (BScPT, ISM certified) of Within: Self Mastery
Through and Beyond Physical Therapy Inc. I acknowledge discussion occurred, and that I understand the discussion,
pertaining to the nature of the proposed assessment along with the proposed assessment’s purpose, anticipated
outcome, and risks. I acknowledge that discussion on alternative conservative avenues to the proposed assessment
were discussed, and I understand those avenues.
------------------------------------------------------------------------------------------------------------------------------------------I, _____________________________________________________, on this date of ______________________________________________
give my express consent to be treated by Lynne Brochu (BScPT, ISM certified) of Within: Self Mastery
Through and Beyond Physical Therapy Inc. I acknowledge discussion occurred, and that I understand the discussion,
pertaining to the nature of proposed treatments along with the proposed treatment’s purpose, anticipated
outcome, and risks. I acknowledge that discussion on alternative avenues to the proposed treatments were discussed,
and I understand those avenues. I acknowledge and understand that there is no guarantee of successful treatment nor
successful outcome.
------------------------------------------------------------------------------------------------------------------------------------------I further give my express consent to reports (initial assessment, progress, and/or discharge) being faxed to my Family
Doctor and other health care professionals I am currently seeing for the same concern. I understand that I will be
supplying Lynne Brochu (BscPT, ISM certified) with private, confidential, personal, and privileged information
including but not limited to my demographic information, current health status, medical history, and current
concern(s). I give my express consent to this sensitive information being supplied for the primary purposes of Lynne
Brochu collecting the information as required by her professional licensing body and sharing this information with
any concurrent health care provider(s). I acknowledge and understand that if my personal health information is
shared with one or more medical professionals that those professionals can rely on the express consent I gave initially
to collect, use, and disclose my information as outlined above.
Signed __________________________________________________ on this date of _________________________
Witness __________________________________________________