Welcome to the Dempsey Center for Quality Cancer Care. Our mission is to provide quality of life services to individuals and families impacted by cancer.
This informed consent document is intended to confirm that you have received information regarding the nature, risks, benefits and alternatives of the Dempsey Center support services (“Services”) you may receive.
I. Description of Services and Treatment.
Adult Oncology Counseling Services: We provide oncology counseling services by licensed mental health professionals (LCSWs and LMSW-CCs, all of whom are either board-certified in oncology [OSW-C] or working toward that designation). Our counseling services are designed to address many of the issues our clients are dealing with, and to provide our clients with an integrated experience for their mind, body, and spirit to enhance their adjustment to and coping across the continuum of the cancer impact from diagnosis through survivorship or bereavement, and to help enhance quality of life.
Risks and Benefits: Counseling is usually beneficial for most clients, but there are no guarantees as to the nature or extent of any particular result and as with any treatment, there are potential, inherent risks. For example, during counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process, however. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits, of course. It is our desire, however, to work with you to attain your personal goals for counseling.
The Healing Tree program provides an array of professionally-led services, centered on educating and supporting children and families around the impact of cancer or cancer-related loss.
HT services may include, but are not limited to: Healing Tree Introductions, individual counseling, family counseling, parent support and education, adventure based therapy, support groups, youth and family focused specialty programs, health and wellness programs and complementary therapy services offered to youth clients.
Risks and Benefits: Counseling is usually beneficial for most clients, but there are no guarantees as to the nature or extent of any particular result and as with any treatment, there are potential, inherent risks. For example, during counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process, however. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits, of course. It is our desire, however, to work with you to attain your personal goals for counseling.
Acupuncture Services: We provide acupuncture services by licensed acupuncturists. Our acupuncture services are intended for stress reduction and may also help to ease other cancer-related symptoms such as pain, anxiety, fatigue, nausea, insomnia and depression. Acupuncture is not intended to constitute and is not a substitute for medical care. Services will not include diagnosis or prescriptions, and nothing said or done in the course of the acupuncture sessions should be construed as such.
Risks: Acupuncture is usually beneficial for most clients, but there are no guarantees as to the nature or extent of any particular result and as with any treatment, there are potential, inherent risks. Complications may arise from receiving acupuncture, including soreness during or after needle insertion and/or with needle withdrawal, minor bruising or bleeding where the needles are inserted, localized infection, feeling faint or fainting, fatigue, nerve injury, punctured organ, dizziness and/or vertigo, and headaches/migraines. Drowsiness may also occur after treatment, and if affected, you are advised not to drive. If your symptoms worsen after treatment you should contact us and tell the acupuncturist.
Contraindications: Certain contraindications may exist to acupuncture, and it is your responsibility to inform your acupuncturist if either (i) you have any of the following: a contagious disease, a fever, have lymphedema, have a bruising or bleeding disorder, have platelet counts lower than 10,000 (thrombocytopenia), white blood cell counts lower than 1,000 (neutropenia), have a history of seizures; or (ii) you are pregnant; or (iii) you have recently been vomiting or if you are taking anticoagulant medications.
If any of these conditions exist, acupuncture may not be appropriate for you at this time.
Massage Therapy Services: We provide massage therapy services by licensed massage therapists. Our massage therapy services are intended for stress reduction and relieving muscle tension, and may also help to ease other cancer-related symptoms such as pain, anxiety, fatigue, nausea and depression. Massage therapy is not intended to constitute, and is not a substitute for medical care. Services will not include skeletal adjustments, diagnoses, or prescriptions, and nothing said or done in the course of the massage sessions should be construed as such.
Risks: Massage therapy is usually beneficial for most clients, but there are no guarantees as to the nature or extent of any particular result and as with any treatment, there are potential, inherent risks. Complications may arise from receiving massage therapy, including bruising, lymphedema, bone fracture, causing a new injury, exacerbating an existing injury or condition, dislodging a blood clot, skin injury, fatigue, dizziness and/or vertigo, inflammation, nausea and headaches/migraines.
Contraindications: Certain contraindications may exist to massage therapy, and it is your responsibility to inform your massage therapist if you are pregnant or have been vomiting, or if you have any of the following: contagious disease, diarrhea, a fever, kidney disease, congestive heart failure, bone metastases, known or suspected deep vein thrombosis, COPD, bruising or bleeding disorder, lymphedema, platelet counts lower than 10,000 (thrombocytopenia) or white blood cell counts lower than 1,000 (neutropenia).
If any of these conditions exist, massage therapy may not be appropriate for you at this time.
Medical Clearance: Please know that we will require a medical clearance from your medical provider before we will render massage therapy services. We will send a form for this purpose directly to your designated provider.
Movement and Fitness Services: By registering for this class you agree to the following: You are participating solely at your own risk, and the Dempsey Center for Quality Cancer Care will not be responsible for any harm or injury you incur as a result of such use. Talk to your licensed medical provider before beginning this class. The information in the following class is not a substitute for, nor does it replace, professional medical advice, diagnosis, or treatment. Do not disregard, avoid or delay seeking medical advice for any reason. Treat yourself with kindness and listen to your body to avoid injury. Please enable your web browser cookies to ensure access to this class.
Nutrition Services:
II. Confirmation of Disclosure of Risks. By signing below, I am acknowledging that I have been informed and understand that:
1. All therapeutic modalities, including counseling and other interventions involve some risk. For example, for some people, there can be uncomfortable feelings and anxiety associated with participating in the Services.
2. There are no guarantees of a successful outcome or of a particular result.
3. If I receive Services in person, regardless of the care taken to provide a sanitized environment and to otherwise avoid the spread of bacteria, germs or viruses, there is some risk that I will be exposed to and have a risk of contracting a virus or other similar condition.
III. Consent to Receive Services. By signing below, I authorize Dempsey Centers and its staff to render the Services to me. The Services may include examinations to assess my status, and the performance of the modalities identified above.
IV. Right to Refuse or Discontinue Treatment: I understand that although I am giving my consent to treatment, I retain the right to refuse any examination, treatment, therapy or modality recommended. I understand that the refusal to undergo any recommended treatment could result in a failure to improve, or even a worsening of my condition or symptoms.
V. Communications. I agree that if I have any questions about the Services that are the subject of this Consent, I can ask, and Dempsey Center and its staff will attempt to fully answer my questions in language or through a mechanism that I can understand. I have been encouraged to ask questions, and to express any concerns I have during the treatment process including if I think that I am not a good fit with a particular care provider. I have been assured that Dempsey Center will attempt to answer any questions and resolve concerns
VI. Emergency Procedure. I understand that the Dempsey Center is not an emergency medical facility. In the event of a life-threatening or other health emergency, I should call 911. In the event of a mental health crisis, I am aware that I can call the Maine State Crisis Hotline at 1-888-568-1112.
VII. Acknowledgement and Authorization to Treat: By signing this Consent form, I certify and confirm each of the following items and authorize the delivery of the Services:
• I have read the contents of this form or it has otherwise been read to, or reviewed with me;
• I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me;
• I have been provided information regarding the risks and benefits of the services and am voluntarily choosing to receive the services;
• I understand that I may stop such treatment or services at any time; and
• I CONSENT to the delivery of the Services.
