It is expected that informed consent is a combination of written and verbal, and as it should be targeted to the individual it is not expected that every detail is in the form. General statements are ok, and should be backed up with information in the case notes.
First of all, read the ESSA Code of Ethics and Professional Conduct that outlines key points of inclusion in your informed consent.
It is important that your informed consent form includes the following;
Purpose – to acknowledge the risks in participating in services
Procedures – outline what sort of activities is the client expected to undertake within the program.
Risks of participating in your services – this is to be written specific to the services you are providing. For example, I understand that I may experience some degree of discomfort during some of the exercises, particularly in the form of breathlessness and a feeling of fatigue in the legs or arms but the exercises will generally be within my normal range of physical activity.
Safeguards – a statement about in case of injury, appropriate care and medical treatment will be made available.
Rights – the client knows of their rights to participate at all times. For example, My participation in this exercise program is entirely voluntary, and I understand I may withdraw from participating at any time without penalty.
Benefits – you can describe the potential outcomes. For example, I understand participating in this exercise program may improve my cardiovascular health, decrease overall fat mass and increase my ability to perform daily activities.
A statement about clients under 18 - For adolescents under the age of 18, a parent or legal guardian will need to provide this acknowledgment. You could even think about having the client sign your clinical notes that you have made after the pre-exercise screening discussion. This way, you are obtaining the client’s consent throughout the whole process and minimise the risk of refusal to sign the informed consent.
Confidentiality and privacy – explain how their details are stored and how you will respect confidentiality/privacy. For example, your information will be stored electronically in an external hard drive protected with a password. Any paper data (such as consent forms and pre-screen documents) will be stored in a locked filing cabinet.
Signature of acknowledgment
Communicate the above in a manner in which the client will understand them, for example some clients may be visually impaired so you can choose to read the information to your client. Beware of using scientific terms or other jargon if it is unlikely to be properly understood.
As with any documentation that may be used in a court of law, what is critical is the fact and content of the documentation so make sure you consider your own protection. Insurance is absolutely essential for any professional working with clients. A standard informed consent form is a good starting point but you still need to make it specific to your services.
Sessions do not always go according to plan and good record keeping will not prevent complaints being made. However, what it will do is assist in responding to such complaints and in defending them. Furthermore, good records should facilitate good communications with clients, such that the prospect of misunderstanding is reduced thereby decreasing the prospect of complaints being made in the first place.
If you have correctly adhered to the informed consent process and your client refuses to sign it you are well advised not to proceed with working with them.
You can also see an FAQ on Informed Consent here