PSYCHOTHERAPY SERVICES AGREEMENT

For Rest + Reconnect Retreat – SEED Lodge

Therapeutic Services Contract

This Psychotherapy Services Agreement (“Agreement”) outlines the responsibilities, expectations, and professional boundaries governing your participation in the psychotherapeutic components of the Rest + Reconnect Retreat(“Retreat”), facilitated by Esther Kalaba, Registered Psychotherapist (CRPO), & Art Therapist (Studio Seed Inc.).

Please read carefully. Your participation indicates informed consent to these terms.

1. Nature of Services

During the Retreat, you will receive psychotherapy services within a group and experiential format. These services may include:

• Somatic psychotherapy

• Trauma-informed breathwork

• Mindfulness-based interventions

• Art therapy

• Psychoeducation on stress, emotional regulation, and the nervous system

• Group process and facilitated discussion

These methods fall within the scope of practice for psychotherapy in Ontario and Quebec.

Services provided during the Retreat constitute psychotherapy, not recreational wellness activities.

2. Purpose & Limits of the Retreat Format

The Retreat is not a replacement for ongoing individual therapy, crisis services, or emergency psychiatric care.

The psychotherapeutic work offered during the Retreat is:

• Exploratory

• Supportive

• Psychoeducational

• Somatically informed

• Group-based

The format is not suitable for individuals currently in acute crisis, including:

• Active suicidal ideation

• Acute PTSD episodes

• Recent psychiatric hospitalization

• Active addiction or withdrawal

• Unmanaged psychosis or mania

If any of these apply, you agree to disclose this prior to participation so that appropriate referrals may be offered.

3. Informed Consent to Psychotherapy

By participating, you acknowledge that psychotherapy involves discussing emotions, life experiences, and relationships, which may evoke discomfort or unexpected feelings. You consent to:

• engaging in therapeutic activities

• participating in group formats

• setting your own boundaries

• communicating when support or pause is needed

You may withdraw from psychotherapy activities at any time.

4. Confidentiality

As your psychotherapist, I adhere to confidentiality standards outlined by the CRPO and professional ethics.

Confidentiality limits include:

• Risk of harm to self or others

• Child or elder abuse

• Court order or legal requirement

• Professional supervision

• Serious risk of harm during group activities

Group Confidentiality:
All participants agree to keep shared information strictly private and confidential.
Although encouraged and expected, confidentiality among participants cannot be guaranteed.

5. Records & Documentation

As a Registered Psychotherapist, I am required to keep confidential clinical records of psychotherapeutic services delivered during the Retreat. These records include:

• dates of service

• clinical notes

• themes discussed

• treatment approaches used

• any relevant disclosures

Files are maintained in accordance with CRPO, PHIPA, and PIPEDA standards.

6. Risks & Responsibilities of Participants

You acknowledge that:

• Psychotherapy can bring up emotional content that may feel challenging

• Somatic work may evoke physical sensations or stored emotion

• You are responsible for informing the therapist of any distress, discomfort, or medical/psychiatric history relevant to your safety

• You will communicate if you need to pause, step out, or receive support

You agree to practice self-care, pacing, and boundary-setting.

7. Emergency & Crisis Protocols

The Retreat is not equipped to provide 24/7 crisis intervention.

In the event of:

• Psychological emergency

• Medical emergency

• Dissociation, panic, or overwhelming distress

You consent to the therapist:

• Pausing your participation

• Providing grounding or stabilizing support

• Contacting emergency medical services if necessary

• Contacting the emergency contact you provided on your intake form

8. Fees & Payment

Retreat fees include:

• Accommodation

• Meals

• Group psychotherapy sessions

• Psychoeducational workshops

• Somatic and art-based therapeutic activities

Fees are:

• Non-refundable

• Transferable to another participant

Insurance receipts for psychotherapy (Ontario & Quebec) are available upon request at the end of the retreat.

9. Boundaries & Dual Relationships

During the Retreat, the therapist has both:

• a facilitator role, and

• a psychotherapist role.

You understand that:

• The therapist maintains professional ethical boundaries at all times.

• Romantic, sexual, or exploitative relationships are strictly prohibited.

• Socializing is permitted in group settings, but professional boundaries remain in place.

10. Use of Touch

No physical touch is used without explicit verbal consent (e.g., grounding techniques, adjustments in somatic practices).
You may decline touch at any time.

11. Substance Use & Safety

The Retreat is drug and alcohol free.
Smoking is permitted off-property only.
Any participant under the influence may be asked to discontinue participation without refund.

12. Voluntary Participation & Right to Discontinue

You may discontinue participation in psychotherapy at any time.
The facilitator also reserves the right to remove a participant from the therapeutic portion or the retreat entirely if:

• their behaviour threatens safety

• they are in psychiatric crisis

• they violate community agreements

A removal for safety reasons does not qualify for a refund.

13. Acknowledgement & Consent

By registering, you acknowledge that you:

✔ Understand the nature of psychotherapeutic services being offered
✔ Consent to group and somatic psychotherapy
✔ Accept the limits of confidentiality
✔ Understand the risks and responsibilities involved
✔ Agree to emergency protocols if required
✔ Have disclosed (or will disclose) relevant medical/psychological information
✔ Understand the cancellation and refund policy
✔ Agree to all terms outlined in this Agreement