Informed Consent: a digital mindfulness-based 12-week remote therapy program for burnout, depression and anxiety symptom treatment
I am interested in participating in a digital mindfulness-based 12-week remote therapy program for burnout, depression and anxiety symptom treatment. This document is intended to provide you with information about this program, as outlined under each section below. Please read and review this document carefully before agreeing to sign.
Confidentiality and Data Collection
Every effort is taken to maintain your personal protected health information in accordance with federal regulations under the Health and Information Portability Act (HIPAA). I have received sufficient information about how data is collected and how my data is used as part of this program. I acknowledge that I have read the “terms of service” (https://www.meruhealth.com/tcs) which describes how my privacy will be maintained and how data will be collected and used by Meru Health. In addition, I have had the opportunity to ask questions and I have received answers to all the questions I have asked.
I understand that this program is currently in a development phase and that if I am eligible, and chose to take part in this program, some information about me will be used as anonymous data to better study and understand the effectiveness of this digital mindfulness-based therapy as a treatment for symptoms of depression, burnout and anxiety. As such, I agree to complete questionnaires about my mood over the course of this 12-week program and up to two years after treatment completion. I understand that any data collected for this purpose will be kept strictly confidential by using aggregate and de-identified data (i.e. combined with other participant data) that is not personally identifiable.
I understand that this service is not intended to be, and does not constitute, a substitute for professional medical advice, diagnosis, or treatment and is offered for informational purpose only. I am aware that the role of the therapist assigned to me as part of my participation in the Meru Health program, is to support me in learning mindfulness and other new skills to better cope with depression, burnout and anxiety, and that contact with a Meru Health therapist does not take the place of a primary health care provider. Moreover, I understand that if I take part in this therapy program, it does not substitute for in-person therapy with a qualified healthcare professional. As such, I have been provided with an Action Plan for Deteriorating Mental Health (https://www.meruhealth.com/action-plan) to use should my symptoms of depression worsen over the course of this program. I have reviewed this plan, had the opportunity to ask questions, and I agree to follow it accordingly. Lastly, I also understand that if my Meru Health therapist believes I would be better served by another form of service (e.g. face-to-face therapy, medical evaluation) over the course of my participation in the program, I will be referred to a psychotherapist or a doctor who can provide such services in my area.
I understand that there may be potential risks and consequences from participating in this digital mobile healthcare program, including, but not limited to, the possibility that my symptoms of depression, burnout and anxiety could escalate or worsen, as is common risk associated with many types of therapies and medical treatments for depression, burnout and anxiety. It is also possible that my symptoms of depression, burnout or anxiety may not improve as a result of taking part in this program. As such, I understand that there might not be any personal gain or benefit for me from taking part in this program.
I have received, read and understood the information outlined above concerning this program. I have had enough time to consider my willingness to participate in the program.
Meru Health, Inc. | 470 Ramona St. | Palo Alto, CA 94301