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SAFE AND SOUND PROTOCOL(SSP) INFORMED CONSENT - ADULT
INTRODUCTION AND BENEFITS
Thank you for agreeing to participate in the Safe and Sound Protocol. This intervention is evidence based, which means that it has been found through research to have a positive impact on individuals who participate in it. I am hoping it will be helpful for you as well.
The Safe and Sound Protocol (SSP) was developed by Stephen Porges, PhD and the Integrated Listening Systems after Dr. Porges has spent forty years of research on the relationship between the Autonomic Nervous System (ANS), auditory sensitivities and social as
well as emotional processes. The SSP is a sound based intervention that has been found to calm physiological and emotional
states. It was designed to reduce stress and auditory sensitivity and enhance social engagement and resilience by stimulating ANS regulation. This is accomplished by exercising and systematically challenging the auditory system with specifically processed or filtered music.
WHAT IS INVOLVED
-If you decide to participate, we will schedule an initial complimentary session of 60-minute duration, allowing for an intake assessment to determine whether SSP intervention is safe for you to use and collect baseline information of your nervous system functioning. This also will
include you experiencing SSP intervention by actively listening to the soundtrack of the 1st hour of SSP Core (out of 5-hr total) for 10-15 minutes to see how your nervous system responds and to determine how many minutes per day you will be listening to produce desired effects
- You must be able to self-administer SSP intervention after Set Up
- I will provide instructions on how to use SSP and answer any questions you might have
- I will also arrange for SSP Set Up, which would involve providing access to the SSP portal
-You will need to have access to computer/cell phone
-Ear-covering earphones are required to participate
-Keeping daily log of how your ANS is doing
-Weekly check-in texts with me
-While listening, assume a comfortable position and engage only in a relaxing non-verbal activity, rest, and/or receive gentle somatic support; you can use any “props” that will make your experience more comfortable (special blankets, etc.)
RISKS
Because the SSP works with the vagus nerve, there is the possibility that you will experience some temporary gastrointestinal symptoms (ex., bowel changes or gas). You also may experience an uptick in strong emotions or auditory sensitivity for a short time. In part, this is
due to the fact that the interventions are “changing” the nervous system into a more settled state, but because this “feels” different, it can be disorienting. As time passes, you should settle into a new, calmer state.
The SSP may be considered a Somatic Intensive. It's best to select a time period that avoids external stressors (ex. traumatic anniversaries, starting a new job) and to keep unnecessary activities and stress to a minimum for each week of and the week or so following completion of
the SSP. It is quite common to feel physically tired during and after the intervention, so getting adequate rest is very helpful.
There may also be risks I cannot predict. If you experience any adverse effects, please contact me immediately via text msg., so I can provide support.
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YOUR RIGHTS
Participation in this intervention is voluntary. You have the right to end your participation at any time. Your confidentiality rights are the same as in a counseling relationship. You have a right to complete confidentiality except in the case of reported child or elder abuse, planned harm to self or others or in the rare case that records are subpoenaed.
RESPONSIBILITIES
It is imperative that you adhere to the schedule and amount of time you are listening to the music we establish. The cost of a 5-hour SSP package is $535.00 payable on the day you sign up. I accept checks or Venmo(___________). Neither SSP intervention nor my services are covered by insurance. In the unlikely event that we determine that it is clinically appropriate to discontinue SSP
intervention, partial refund may be requested.
I understand the Risks and Benefits associated with Safe and Sound Protocol (SSP) and agree
to participate