Patient Consent & Liability Agreement

Whole Living by CK Harris  ·  Occupational Therapy Services  ·  wholelivingck@gmail.com

Dr. Cameron Harris, OTD, OTR/L  ·  Virtual Practice — North Carolina Licensed  ·  Private Pay Only

1. Patient Information

2. Description of Services

Whole Living by CK Harris provides virtual occupational therapy (OT) services through the practice’s configured Sessions Health client-portal and telehealth workflow. Services are provided by Dr. Cameron Harris, OTD, OTR/L, a licensed occupational therapist. All services are:

• Delivered entirely online — no in-person component
• Private pay only — no insurance billing
• Available to adults 21 years of age and older
• Licensed and available to clients physically located in North Carolina only

Current service pathways: Comprehensive OT Evaluation ($300, required before treatment); Single Individual OT Session ($175 / 60 minutes); New-Client First-Care Package ($1,080: evaluation + six 60-minute individual visits); Continuing 6-Visit Bundle ($840: six 60-minute visits); 12-Week Individual Plan ($1,600: twelve 60-minute visits in two clinically reviewed $800 phases); and Small-Group OT Series ($450: six 30-minute visits, Saturdays 9:30–10:00 AM ET, 2–3 participants). The First-Care Package includes the evaluation; all other treatment pathways require a clinically current comprehensive Whole Living evaluation and active plan of care already on file. Treatment, continuation, and group participation remain subject to clinical appropriateness.

3. Telehealth Consent

Telehealth involves the delivery of occupational therapy services using interactive audio and video technology while the provider and I are in separate physical locations. By signing this agreement, I acknowledge, understand, and voluntarily consent to the following:

• Telehealth sessions are conducted through the practice’s approved telehealth technology.
• I consent to the use of audio and visual technology for assessment, consultation, and treatment.
• I understand that telehealth carries inherent limitations compared to in-person care, including but not limited to the inability of the provider to perform hands-on assessment, manual techniques, or physical intervention.
• I understand that the provider cannot physically assist, guide, spot, or intervene during any activity, and that I am responsible for my own physical safety during sessions.
• I understand that the same standards of care, professional ethics, and confidentiality that apply to in-person occupational therapy apply to telehealth.
• I understand and accept that technology may fail, disconnect, lag, or otherwise disrupt a session, and that such disruptions are not the fault or responsibility of the provider. If a disruption occurs, the provider may attempt to reconnect, continue by telephone, or reschedule at their professional discretion.
• I am responsible for providing my own suitable, functioning device, a stable internet connection, and a private, safe, quiet, and adequately lit environment for each session.
• I understand that Whole Living currently provides occupational therapy services only when I am physically located in North Carolina. I agree to truthfully confirm and disclose my physical location at the beginning of every session. I understand that providing false location information may result in immediate termination of services without refund and may constitute a violation of law.
• I understand that telehealth may not be appropriate for every individual or condition, and that the provider may determine at any time that telehealth or occupational therapy is not suitable for my needs and may refer me elsewhere.
• I understand the potential benefits of telehealth, that no specific outcome or result is guaranteed, and that I may expect the same professional standard of care as in-person services within the limits described above.
• I understand that I have the right to withdraw my consent to telehealth at any time, and that withdrawal will not affect my right to seek care through other means, but does not entitle me to a refund of services already paid for or rendered.
• I have had the opportunity to ask questions about telehealth and have received answers to my satisfaction.

4. Privacy & Health Information

Whole Living by CK Harris protects health information in accordance with applicable privacy laws, professional confidentiality requirements, and HIPAA when applicable to the practice and transaction. Health information is handled through approved clinical workflows. By signing this agreement, I acknowledge and authorize the following:

• The provider may collect, use, and store my PHI for the purpose of providing, documenting, scheduling, and coordinating my occupational therapy services.
• The provider may maintain session records, assessment findings, treatment plans, and related documentation in accordance with applicable law and professional record-retention requirements.
• Clinical intake, signed forms, health information, scheduling, and treatment documentation are maintained through the practice's designated clinical system and Sessions Health client-portal workflow, together with other approved practice tools as applicable. Ordinary email and public website forms are not intended for detailed clinical information.
• The provider uses third-party service providers strictly necessary to deliver services (such as the configured telehealth/clinical system and payment processor), who are permitted to access only the information necessary to perform their function. The provider uses a practice-approved clinical technology and vendor arrangements reviewed for the intended use.

I understand and the provider affirms that:

• My information will not be sold, rented, traded, or shared with any third party for marketing or commercial purposes, ever.
• My information will not be disclosed to anyone outside the business except: (a) to the service providers necessary to deliver the service; (b) with my written authorization; or (c) when required or permitted by law.
• The provider may be legally required or permitted to disclose PHI without my authorization in limited circumstances, including to comply with a valid court order or subpoena, to satisfy mandatory reporting obligations (such as suspected abuse or neglect), or to prevent serious and imminent harm to myself or others.
• No method of electronic transmission or storage is completely secure. While the provider uses reasonable safeguards, absolute security cannot be guaranteed, and I accept this inherent risk of telehealth and electronic communication.
• I have been informed of the provider's privacy practices and may review the full Privacy Policy at any time.

5. Financial Agreement & Payment Policy

5.1 No Refund Policy

5.2 Cancellation & Missed Session Policy

I agree to the following cancellation terms:

• A minimum of 24 hours' advance written notice is required to reschedule or cancel a session
• Sessions cancelled or missed without 24 hours' notice will be counted as a completed session and deducted from the purchased bundle — no exceptions
• Repeated last-minute cancellations may result in termination of services without refund
• Dr. Harris reserves the right to cancel sessions due to illness, emergency, or technical failure with no charge to the patient; affected sessions will be rescheduled

5.3 Session Expiration

All purchased sessions must be used within six (6) months of the purchase date. Sessions unused after this period expire with no refund, credit, or extension. Consistent attendance is strongly encouraged for optimal therapeutic outcomes.

5.4 Evaluation & Re-Evaluation Policy

All treatment is based on a comprehensive Whole Living occupational therapy evaluation and an active plan of care. Each 6-session individual bundle includes a progress reassessment and plan-of-care review during the final treatment visit at no additional charge. A comprehensive re-evaluation is required before further individual treatment when 6 months have passed since the most recent comprehensive evaluation or after 18 individual treatment visits (3 bundles), whichever comes first, and sooner whenever clinically indicated because of a meaningful change in function, medical status, safety, goals, or telehealth appropriateness. Continued skilled OT is never automatic and remains subject to clinical appropriateness. No physician referral is required by NCBOT for private-pay occupational therapy evaluation or treatment in North Carolina.

• A comprehensive Whole Living OT evaluation and active plan of care are required before any treatment.
• The First-Care Package includes the initial comprehensive evaluation. The Single Individual OT Session, Continuing Bundle, 12-Week Plan, and Small-Group Series require a clinically current evaluation already on file; a new evaluation is not automatically included in those treatment fees.
• When clinically indicated or when the comprehensive re-evaluation threshold is reached, a comprehensive re-evaluation must be completed before further treatment.
• A meaningful change in function, medical status, safety, goals, or telehealth appropriateness may require earlier re-evaluation.
• I understand that evaluation and re-evaluation are clinical safeguards used to keep the plan of care safe, current, and appropriate.

6. Scope of Practice & Limitations

Occupational therapy addresses functional performance in daily life activities. I understand that services provided by Whole Living by CK Harris do not include and should not be interpreted as:

• Medical diagnosis of any condition
• Prescription or recommendation of medications
• Mental health crisis intervention or psychotherapy
• Physical therapy, speech therapy, or any other licensed discipline
• Emergency medical care of any kind

If Dr. Harris determines that my needs exceed the scope of occupational therapy or telehealth services, I may be referred to in-person or specialist care. I agree to seek emergency services (911) in any life-threatening situation and not to rely on OT services as emergency care.

7. Assumption of Risk & Limitation of Liability

7.1 Assumption of Risk

I understand and voluntarily accept that participation in occupational therapy — including any exercises, physical activities, movements, recommendations, home programs, or use of equipment or household items suggested during sessions — carries inherent risks. These risks include, but are not limited to, physical discomfort, muscle soreness, strain, injury, aggravation of a pre-existing condition, falls, or other adverse events. I acknowledge that:

• I am participating voluntarily and at my own risk.
• I am responsible for consulting my physician before beginning any new physical activity or program recommended during services, and for disclosing any condition that may affect my safe participation.
• I am solely responsible for performing all activities safely, within my own physical limits and abilities, and in a safe environment.
• Because services are provided virtually, the provider cannot physically observe my entire environment, cannot physically assist or spot me, and relies on the accuracy of the information I provide.
• I will stop any activity immediately and seek appropriate medical attention if I experience pain, dizziness, distress, or any concerning symptom.

7.2 No Guarantee of Outcomes

I understand that occupational therapy outcomes vary from person to person and depend on many factors, including my own participation, effort, health status, and circumstances beyond the provider's control. I acknowledge that the provider has made no promise, representation, warranty, or guarantee of any specific result, improvement, recovery, cure, or outcome. All services are provided on an "as is" and "as available" basis without warranties of any kind, whether express or implied, including any implied warranty of merchantability or fitness for a particular purpose.

7.3 Limitation of Liability

To the fullest extent permitted by law, I agree that Whole Living by CK Harris, Dr. Cameron Harris, and any affiliated persons, contractors, or agents (collectively, the "Provider") shall not be liable for any indirect, incidental, special, punitive, or consequential damages of any kind arising out of or relating to the services or my use of the website, including but not limited to personal injury, bodily harm, property damage, lost income, emotional distress, or damages resulting from:

• Technology failures, disconnections, delays, or interruptions;
• My own acts, omissions, or failure to follow guidance or safety instructions;
• My performance of any activity or exercise in an unsafe manner or environment;
• The acts, omissions, or disclosures of any other group session participant;
• Any decision I make regarding my own health or care.

Cap on Liability. In no event shall the Provider's total aggregate liability to me for any and all claims arising out of or relating to the services exceed the total amount I actually paid to the Provider for the specific service giving rise to the claim.

7.4 Waiver of Claims & Release

To the fullest extent permitted by law, I hereby waive, release, and discharge the Provider from any and all claims, demands, causes of action, damages, liabilities, or expenses of any kind, whether known or unknown, arising out of or related to my participation in services, except for claims arising from the Provider's gross negligence or willful misconduct that cannot be waived under applicable law.

7.5 Indemnification

I agree to indemnify, defend, and hold harmless the Provider from and against any claims, liabilities, damages, losses, or expenses (including reasonable attorneys' fees) arising out of my breach of this agreement, my misuse of the services, my violation of any law, or my violation of the rights of any third party.

7.6 Acknowledgment

I acknowledge that I have read and understood this section, that I have had the opportunity to ask questions, that I am signing it freely and voluntarily, and that some jurisdictions do not allow certain limitations, in which case those limitations apply to the greatest extent permitted by law.

7A. Recording & Confidentiality of Sessions

Sessions are private and confidential. I agree that:

• I will not record, screenshot, photograph, live-stream, or otherwise capture any portion of any session (audio, video, or images) without the provider's prior written consent.
• This prohibition applies to both individual and group sessions.
• If the provider ever wishes to record a session for documentation or supervision, my separate written consent will be obtained beforehand.
• Unauthorized recording or distribution of any session is a violation of this agreement and may be unlawful.

8. Emergency Procedures

In the event of a medical emergency during a virtual session:

• I agree to immediately call 911 or have someone else do so on my behalf
• I understand that Dr. Harris, as a virtual provider, cannot physically assist me
• I authorize Dr. Harris to contact my emergency contact if I appear to be in distress and am unresponsive
• I agree to maintain an up-to-date emergency contact on file

9. Patient Rights & Responsibilities

My Rights as a Patient

• To be treated with dignity, respect, and cultural sensitivity at all times
• To receive clear explanations of my assessment findings, goals, and treatment plan
• To participate in the development of my goals and treatment decisions
• To refuse any treatment or activity at any time, understanding this may limit therapeutic outcomes
• To ask questions and receive honest, thorough answers
• To discontinue services at any time (subject to the no-refund policy)

My Responsibilities as a Patient

• To attend all scheduled sessions or provide 24-hour notice of cancellation
• To provide accurate and complete health information at all times
• To notify Dr. Harris of any changes in my health status, medications, or circumstances
• To participate actively and honestly in my therapy
• To treat Dr. Harris and any group participants with respect and professionalism
• To ensure a private, appropriate environment for telehealth sessions

10. Termination of Services

Whole Living by CK Harris reserves the right to terminate services without refund for the following reasons:

• Verbal abuse, harassment, or disrespectful behavior toward Dr. Harris or group participants
• Repeated violation of the cancellation policy
• Provision of false or fraudulent health information
• Behavior that poses a risk to the safety of others
• Noncompliance with reasonable treatment recommendations that endangers health or safety

11. Governing Law & Dispute Resolution

This Agreement shall be governed by and construed in accordance with the laws of the State of North Carolina. Any dispute arising under this Agreement shall be resolved through binding arbitration conducted by a mutually agreed-upon neutral arbitrator. I waive any right to a jury trial in connection with any dispute arising from this Agreement.

12. Entire Agreement & Severability

This Agreement constitutes the entire understanding between the parties regarding its subject matter and supersedes all prior discussions and agreements. If any provision of this Agreement is found to be invalid or unenforceable by a court of competent jurisdiction, that provision shall be limited or severed to the minimum extent necessary, and the remaining provisions shall continue in full force and effect. The failure of the provider to enforce any provision shall not be deemed a waiver of that or any other provision. This Agreement is binding upon my heirs, executors, administrators, and assigns.

Electronic Signature. I agree that my electronic signature, initials, and any electronic acknowledgment I provide on this document have the same legal force and effect as a handwritten signature, consistent with the Electronic Signatures in Global and National Commerce Act (E-SIGN) and applicable state law. I consent to conduct this transaction electronically.

Effective Date and Duration. This Agreement is effective as of the date I sign it and remains in effect for the duration of my care and thereafter with respect to any provisions that by their nature should survive termination, including the confidentiality, assumption of risk, limitation of liability, waiver, indemnification, and dispute resolution provisions.