Consent and Discretion Agreement
last updated: July 27, 2022
As a client of Elle Fox you are asked to review the following consent and discretion agreement. These statements must be agreed upon prior to the initiation of services. If you have any questions or concerns, please speak them with an honest mind and heart. Open communication is highly appreciated.
As a client and/or provider of somatic healing with bodywork, energy healing, and intuitive arts… (And as a conscious, breathing human…)
• I take full responsibility for my body and my actions towards other people. I will not place intentional harm onto myself or another person.
• I have the right to feel safe and to say NO when it feels right to do so. I will speak up when I am feeling uncomfortable.
• I have the right to say YES when it feels right to do so. I will give permission on how I am to be touched.
• I have the right to change my YES to a NO. I can change my mind. Consent is fluid and can change.
• I will ask permission to touch another person and respect their boundaries. I will not touch before asking or without given permission.
• I will provide clear boundaries on where and how I desire to be touched.
As a provider, Elle agrees to the following statements:
• I will not share client’s private information with anyone.
• I will not discuss session details with anyone without written permission from the client. I will not falsify testimonials based on your experiences. You have full ownership of what your testimonial.
• I will not share session notes and will use best practices to keep them private. I may keep notes on sessions for the following purposes: to remember who you are, your requests, your goals, previously discussed likes, don’t likes [face cradle, hot stones, etc.], and any other information that is helpful as we progress. Your full name or phone number are never written down.
• I will not cause harm to your reputation or go public with what occurs in our private sessions beyond what is necessary to protect my bodily rights.
• I will not pursue a personal relationship outside of professional boundaries.
As a client, you agree to the following statements:
• I will not share my provider’s private information with anyone beyond what is necessary to make referrals.
• I will not post my provider’s information on any website, including review sites, advertising sites, or other website without her direct permission in writing.
• I will not infringe on my provider’s basic copyright protection (posting pictures without permission, using direct language from provider’s personal social media accounts or advertisements, etc.)
• I will not pursue a personal relationship with my provider outside of professional boundaries.
• I will not cause harm to the reputation of my provider beyond what is necessary to protect my bodily rights.
• If I see my provider listed on a site that does not seem to align with her scope of practice, I will notify my provider.
• I understand that my name, phone number, email address, and/or other information may be requested and used to verify who I am. I agree to provide all information requested for my provider to appropriately screen me.