Liability Waiver
Waiver and Informed Consent for By Repose LLC & Repose Psychotherapy
Yoga, Dance and Wellness Offerings
By Repose LLC is a studio offering yoga-informed, dance movement, creative arts, and meditation group classes and wellness workshops and events. Some studio classes and offerings may be provided through Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC), but studio offerings should not be considered a substitute for the mental health services, treatment, or diagnosis provided within the scope of individual psychotherapy through Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) or any other licensed mental health provider or clinic. Those under 18 years of age must have this form acknowledged by a parent or guardian.
Live Online and Livestream Classes: By participating in live online, livestream, or recorded movement, yoga, dance, meditation classes, workshops, groups or any other wellness programs, I hereby release By Repose LLC and Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) and any instructors and/or therapists from responsibility for any injuries I may sustain as a result of participation in the classes or programs presented by the studio, including any online pre-recorded or live streamed classes. I am aware that the instructor cannot see me and may not be able to offer personalized instruction, and therefore I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the classes or programs offered through the studio. I accept that neither the instructor/therapist, nor the hosting studio or therapy practice, is liable for any injury, or damage, to person or property, resulting from taking the class or engaging in the program.
On-Demand Classes: By participating in on-demand recorded movement, yoga, dance, meditation classes or any other wellness on-demand or pre-recorded programs, I hereby release By Repose LLC and Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) and any instructors and/or therapists from responsibility for any injuries I may sustain as a result of participation in the classes or programs presented by the studio, including any online pre-recorded class. I am aware that the instructor cannot see me and may not be able to offer personalized instruction, and therefore I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur as a result of participating in the classes of programs offered through the studio. I accept that neither the instructor/therapist, nor the hosting studio, is liable for any injury, or damage, to person or property, resulting from taking the class. I understand and authorize the $.01 processing fee to access on demand videos and authorize these charges.
University Student Membership: Repose is an in-network provider for NYU Wellfleet Student Health Insurance and Aetna Preferred Plan for Columbia University students and will directly bill insurance for these drop-in group therapy class offerings. If you fail to notify us that your insurance has lapsed or is no longer active for any reason, you will be billed the full amount of the Repose Priority membership fee ($39/week). On-demand video library is available as part of your studio membership with a $0.01 processing fee per class that is not covered by insurance.
Private Group Therapy Workshops: Please note that group therapy workshops (such as the DBT or Body Positivity groups) are not included with memberships and are offered from Repose Psychotherapy (owned by Mary Breen LCSW PLLC). These offerings may require a preliminary consultation to join and are subject to the standard copay per session as determined by your individual insurance provider. Additionally, these closed group therapy workshops have a 48 hour cancellation policy. Without 48 hours advance notice, you are responsible for the full amount of the group session. If you purchased a session package, a no-show or late cancellation will count as one used session. Thank you for respecting your provider’s time and the time that has been reserved specifically for you.
Private Individual Dance Movement, Art Therapy, and Therapeutic Yoga Sessions: Please note that individual Dance Movement, Art Therapy, and Therapeutic Yoga Sessions are not included with memberships and are offered from Repose Psychotherapy (owned by Mary Breen LCSW PLLC). These offerings may require a preliminary consultation to join and are subject to the standard copay per session as determined by your individual insurance provider. Additionally, these private, individual sessions have a 48 hour cancellation policy. Without 48 hours advance notice, you are responsible for the full amount of the session. If you purchased a session package, a no-show or late cancellation will count as one used session. Thank you for respecting your provider’s time and the time that has been reserved specifically for you.
Events: Please note that studio events are not included with membership unless otherwise indicated. Events may require pre registration and depending may be subject to a copay as determined by your insurance provider or may be ineligible for insurance reimbursement and therefore will be offered for a cost. Events will be subject to their own cancellation policy which, if registered, you will consent to separately.
Cancellation Etiquette and Policy: In order to value the time your therapist instructor has set aside for drop-in studio group therapy classes offered through your student membership, you should provide 24 hours advance notice of cancellation. For emergencies or when 24 advance notice is not possible for studio drop-in group classes, please notify your instructor through your account on www.byrepose.studio. All bookings for therapy group classes may be managed via this account.
In accordance with our cancellation policy, clients are responsible for full payment of any group therapy workshop or individual sessions not cancelled at least 48 hours in advance of a scheduled session start time. If you purchased a session package, a no-show or late cancellation will count as one used session. Thank you for respecting your provider’s time and the time that has been reserved specifically for you.
Studio Closure and Class Cancellation: Repose Studio is closed on the following US holidays: New Years Day, Memorial Day, July 4th, Labor Day, Thanksgiving Day, and Christmas Day. The studio may close or classes may be cancelled from time to time for workshops, maintenance, instructor time off, and other matters as determined necessary by management. If a class is cancelled, you will receive notice by email to the email address that you have used to create your studio account. The studio schedule will have the most up-to-date class listings.
Billing: For all administrative or billing matters, please contact: billing@byrepose.com and our office will respond during regular business hours between 9am and 5pm EST Monday-Friday. Please note that any credit card charges for memberships, packages, programs or events incurred may be reflected on your credit card statement as the following entities: By Repose Psychotherapy, By Repose LLC, or Mary Breen LCSW PLLC.
Crisis Services: Please note that Repose does not provide immediate, crisis intervention services. If you are experiencing a medical or psychiatric emergency, call 911 or use a free crisis resource available 24/7.
Email Consent: As a multidisciplinary practice, Repose is affiliated with a wellness studio and clinical psychotherapy practice. From time to time, we send our clients email updates that may include helpful tips to support your mental health, new group and studio offerings, and practice updates. By signing this form, you are consenting to receive these optional emails with the email address you have provided us to keep on file. Please note that your consent to opt into Repose emails may be revoked by you at any time. As per your rights as a client, under no circumstances will your protected health information (PHI) be used outside of your treatment at Repose nor disclosed without your explicit written permission. For more information regarding practice policies please review our Practice Policies Form.
Agreement & Informed Consent to the Terms and Conditions of this Waiver:
By checking the box, I am giving my consent to receive email from Repose and understand that no information other than my name and email address will be used without my explicit consent. I consent to receive correspondence from all Repose companies which includes but is not limited to the following entities: By Repose LLC, By Repose Psychotherapy, and Mary Breen LCSW PLLC.
By checking the box, I understand and consent to the information contained in this waiver. I, the undersigned, understand that therapeutic movement and creative arts classes (including, but not limited to the following activities: dance movement, yoga, meditation, breathwork, and/or creative arts) are not a substitute for medical attention, examination, diagnosis, or treatment. I should consult a physician prior to beginning any active program, including By Repose LLC and Repose Psychotherapy studio classes. I recognize that it is my responsibility to notify my instructor by private chat of any serious illness or injury before every class. I will not perform any postures, positions, or movements to the extent of strain or pain. If at any time during participation in a studio class, you feel discomfort or strain, gently come out of the posture and/or stop engaging in the activity. You may rest at any time during the class. It is important in dance movement, breathwork, meditation, and yoga that you listen to your body, and respect its limits on any given day. I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the program.
By checking the box, I acknowledge and accept the above conditions contained in this waiver. I understand that memberships will be charged on my credit card on file to By Repose LLC unless I have University Student Membership for which Repose (owned and operated by Mary Breen, LCSW) will bill my insurance for the therapy group classes that I have booked or for individual therapy group workshops or sessions. Please note that the $0.01 process fee to access the On-Demand Student Library is not reimbursable by insurance. For University Student Memberships: if you fail to notify Repose that my insurance coverage has lapsed, I understand I will be responsible for the full membership fee of $39/week. Additionally, I agree to provide 24 hours advance notice to the best of my ability for cancellations of drop-in studio group therapy classes.
BY CLICKING ON THE CHECKBOX, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND CONSENT TO THE ITEMS CONTAINED IN THIS DOCUMENT.