Informed Consent & Yoga Therapy Scope of Practice for Quiet the Noise Yoga Therapy
Please complete this consent and scope of practice form prior to our first visit. Thank you.

Om Shanti. Peace. 
Katie
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What is yoga therapy?

Yoga Therapy is a collaborative, client-centered approach that uses evidence-informed yogic tools, such as breathwork, movement, guided relaxation, meditation, chanting, lifestyle awareness, and self-inquiry, to support physical, mental, emotional, and energetic well-being.

Yoga Therapy is intended to supplement your existing healthcare support systems, not replace them.

Client/Yoga Therapist Agreement

In consideration of receiving yoga therapy services provided by Katie Arnold, I hereby declare as follows:  

  • That Katie Arnold has informed me, and I am aware, that they are not licensed under the laws of this state to practice any form of medicine. 

  • That they have stated they will neither diagnose nor prescribe for any condition or problem from which I may appear to be suffering.

  • I understand a Yoga Therapy Session is not a substitute for medical treatment.

  • I understand that the said individual has informed me that no guarantee or promises of cures have been or will be made to me.

  • I understand that Yoga Therapy is an educational process for me to learn self-care techniques that I myself deem useful.

  • That I am 18 years of age or older, or have the signature below of my Legal Guardian.

Client Responsibilities

You agree to provide accurate and complete information regarding your health history, symptoms, medications, and any changes to your physical or mental well-being. This information is necessary to ensure your safety during yoga therapy. Additionally, you agree to:

  • Seek immediate medical or mental healthcare when necessary.

  • Practice self-awareness and honor your limits.

  • Ask questions anytime something feels unclear or uncomfortable, and communicate openly about how the practices are making you feel, so adjustments can be made as necessary.

  • If you become pregnant or suspect you may be pregnant, you agree to inform me so we can adjust your therapeutic practices safely.

Risks & Benefits
Potential Benefits
  • Improved regulation of the nervous system

  • Increased body awareness

  • Reduced stress, anxiety, or pain

  • Enhanced mobility, balance, and stability

  • Emotional support, empowerment, and clarity

  • Tools for resilience and self-care

Potential Risks

While yoga therapy is generally gentle and safe, possible risks include:

  • Temporary discomfort or muscle soreness

  • Emotional release during or after sessions

  • Unexpected personal insights or memories

  • Aggravation of existing symptoms if you push beyond your limits

You agree to practice at a pace that feels safe for your body and communicate if anything feels uncomfortable.


Confidentiality

Your personal information and anything shared during sessions will remain confidential except in cases where:

  • You provide written permission to share with another provider;

  • I am legally required to report risk of harm to yourself or others;

  • There is suspicion of abuse of a minor, elder, or vulnerable adult;

Payment, Cancellation & Logistics
Session Length
  • Initial Intake Session: 60–90 minutes

  • Ongoing Yoga Therapy Sessions: 45–60 minutes
    Session length is determined based on your needs and the therapeutic plan we develop together.

Session Location

Yoga therapy sessions are offered in the following formats:

  • In-person at my office

  • Online via Zoom

  • Home sessions may be approved on a case-by-case basis when appropriate to the client’s needs. (Additional fees apply).

Payment Policy

Payment is due at the time of booking. A card is stored securely on file to reserve your session. All payments are non-refundable.

For home visits, an additional travel fee will be discussed and agreed upon before scheduling.


Cancellation & Rescheduling Policy

I value your time and mine. To maintain clear boundaries and a consistent therapeutic relationship:

  • Cancellations or rescheduling must be made at least 24 hours prior to your appointment.

  • Cancellations made within 24 hours and all no-shows will be charged the full session fee.

  • If you arrive late, your session will still end at the scheduled time, and the full rate will apply.

If I need to reschedule a session, I will provide as much advance notice as possible.


Late Arrival Policy

To respect all clients’ scheduling, sessions begin and end at the set time. If you are late, the session will continue for the remainder of the appointment and will be charged in full.


Between-Session Support & Communication

Email is the primary method of communication outside of sessions. You are welcome to email questions or updates, and I will respond within 48 hours during business days.
Any additional recordings, practices, or resources may be shared on a case-by-case basis, depending on your therapeutic plan.


Crisis Support

Yoga therapy is not a crisis or emergency service. If you are experiencing a mental health or medical emergency, please contact local emergency services or a crisis hotline immediately.


Telehealth/Virtual Sessions (If Applicable)

Virtual yoga therapy may involve additional considerations. I understand that technical issues may occur during virtual sessions and that privacy cannot be guaranteed on my end of the connection. I do my best to ensure my space is private and secure. You agree to:

  • Practice in a clear, safe space free from hazards;

  • Position your camera so I can observe movements appropriately.

  • Ensure privacy to maintain confidentiality.

Recording Consent (If Applicable)

On occasion, I may offer to record a short personalized practice for your use between sessions. I will never record a session, in whole or in part, without your explicit permission. All recordings created for you are for personal use only and may not be shared publicly.

Acknowledgment & Consent *
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Acknowledgment & Consent *
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Acknowledgment & Consent *
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Acknowledgment & Consent

By signing below, you acknowledge that:

  • You have read and understand the information in this document;

  • You understand the scope and limitations of yoga therapy;

  • You understand the potential risks and benefits;

  • You agree to participate voluntarily and may withdraw at any time.

By typing your full legal name below, you acknowledge and agree to the policies outlined above. This typed name serves as your electronic signature. *
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A copy of your responses will be emailed to the address you provided.
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