Walk & Talk Therapy
Liability Waiver/Informed Consent Form
"I __________________________ have enrolled in the service called Walk & Talk Therapy as
offered by Kierstin Oliver, LCPC-c. Walk & Talk therapy is a form of psychotherapy that incorporates
walking while talking about personal issues and therapeutic resolutions. I recognize that complete
confidentiality cannot be maintained in this venue, and I accept the possibility that other people may
hear parts of my conversation. I recognize that this form of therapy involves physical activity
including, but not limited to, cardiovascular activity. I hereby affirm that I am in good physical
condition and do not suffer from any known disability or condition which would prevent or limit my
participation in this form of therapy. I acknowledge that my enrollment and subsequent participation is
purely voluntary and in no way required by Kierstin Oliver, LCPC-c"
"In consideration of my participation in this form of therapy, I, ____________________________ ,
hereby release Kierstin Oliver, LCPC-c from any claims, demands, and/or causes of action as a result
of my voluntary participation and enrollment."
"I fully understand that I could injure myself as a result of my enrollment and subsequent participation
in this form of therapy and I, _________________________, hereby release Kierstin Oliver, LCPC-c
from any liability now or in the future for conditions that I may obtain. These conditions may include,
but are not limited to heart attacks, muscle strains, muscle pulls, muscle tears, shin splints, injuries to
knees, injuries to back, injuries to foot, or any other illness or soreness that I may incur."
I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE
STATEMENTS.
_____________________________(Patient signature)