ARCHIVED: Appendix F: Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse – Plain language consent forms
The following form was created by a survivor who revised a "standard" consent form used in a physical therapy clinic to illustrate how Plain Language can be used to create forms that are easier to understand. Clinicians are urged to work with both legal advisors and clients to develop forms that include all legal requirements but are written in Plain Language.
Consent Form for Examination and Treatment by a Physical Therapist
I am about to be examined and treated by a physical therapist and her/his assistants.
In order for me to be properly examined or treated, I will need to wear shorts and a T-shirt. The physical therapist will need to observe my body while it is still and while it is moving. It will be necessary for the therapist to touch and move my body in assessment and treatment. Should I feel uncomfortable about the assessment and treatment process at any time, I can inform the physical therapist and request that assessment and/or treatment be stopped. I can have someone else in the room with me; either a friend or relative, or someone else from the clinic, if available. In the latter case, I can choose the gender of this person.
I will need to tell the physical therapist about my health problems, both past and present. The therapist will ask my permission to contact my doctor if he or she finds any new problems. I am aware that all information I disclose and all information that will be charted is confidential.
Physical therapy treatment may involve: __________________(plain language, be specific). Soreness after treatment is common because joints and muscles are stretched. If I have any other symptoms, I will tell my physical therapist.
My signature below indicates that I understand all of the above information.
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