Please read this informed consent document carefully. It is a requirement to begin Surrogate Partner Therapy (SPT). It is important that you have the ability to make your own decisions about treatment. You have the right to ask questions about recommended treatments before signing this agreement.
SPT is a collaboration between a therapist and a surrogate partner for the well-being and advancement of a client looking to overcome limitations in physical or emotional intimacy. The therapist provides verbal support, and the surrogate partners with the client in experiential exercises that provide the opportunity to put the theory into practice.
My decision to consent to treatment is voluntary. I am not pressured into treatment by my Therapist, family or friends.
I understand what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if I do not follow through with treatment.
I am an adult with the capacity to make a voluntary and informed decision to consent to or refuse treatment.
I understand the duration of my therapy depends on how I progress through the process.
I understand that my relationship with the surrogate will end and that the decision to
begin closure is ideally made jointly by me, my Therapist, and my Surrogate Partner. However, I understand that all parties retain the right to suspend the working
relationship at any time. If circumstances interfere with the natural conclusion of our work, I agree to one closing meeting with my Surrogate Partner and my Therapist
announcing my intention to suspend therapy.
I understand my relationship with my Surrogate Partner is limited to SPT and that after
closure of the therapy, I will not have contact for a minimum of six months. I understand that SPT is provided for my education and personal growth. These services are not a substitute for the services of a medical professional or a psychotherapist. My Surrogate Partner is not qualified to diagnose, prescribe, or treat any physical or mental illness.
I understand that I may experience physical contact and emotional attachment to my surrogate.
I understand that as part of my personal growth, I may experience uncomfortable feelings during the process and potential for grief when the relationship is terminated.
I understand that any touch will be given only at my request and solely for my own benefit, education, and pleasure. I agree to guide my Surrogate Partner’s touch to ensure that it is always beneficial, educational, and pleasurable for me.
I agree to make a commitment to the SPT process by:
–Voicing my opinions, thoughts and feelings honestly and openly, whether positive or negative
–Being actively involved during sessions
–Completing homework assignments, if given
–Experimenting with new ways of doing things
