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Clinical Governance Policy

DRAFT — for professional sign-off Faresay Ltd·25 June 2026

⚠️ DRAFT v0.1 — for clinical advisor + legal review. NOT clinical or legal advice. Must be validated by a qualified clinical lead before use. Last updated: [PLACEHOLDER: date]

Faresay Clinical Governance Policy

1. Purpose and Scope

1.1 Purpose

1.1.1 This Clinical Governance Policy (the "Policy") sets out the framework through which Faresay seeks to assure the quality and safety of the clinical services delivered by independent mental-health professionals through the Faresay marketplace platform.

1.1.2 The Policy describes how clinical standards are set, how practitioners are verified and monitored, how clinical quality and safety are overseen, and how clinical risks, incidents, and complaints are managed. Its objective is to support safe, ethical, evidence-informed care while preserving each practitioner's independent professional clinical judgement.

1.1.3 Faresay provides the technology and marketing platform (software, discovery, scheduling, payments, client acquisition, and administrative support). Faresay does not provide clinical services, does not employ practitioners to provide clinical services, and is not a party to the clinical relationship. The practitioner provides the clinical service and owns the clinical relationship and the clinical record. This Policy is a governance and quality-assurance framework for the marketplace; it is not, and must not be read as, Faresay directing, controlling, or interfering with any practitioner's clinical judgement.

⚠️ COUNSEL: The boundary between (a) legitimate marketplace quality/safety governance and (b) the practice of psychology/medicine or the exercise of clinical control matters for corporate-practice-of-medicine / corporate-practice-of-psychology (CPOM) doctrine, fee-splitting rules, and the MSO / "friendly PC" structure. The whole Policy must be reviewed by US healthcare-regulatory counsel (per state) and UK counsel to confirm it does not, in substance or appearance, transfer clinical control to a non-clinical entity. See therapist-agreement.md clauses 2.4–2.6.

1.2 Scope

1.2.1 This Policy applies to:

1.2.2 Territory. This Policy applies to Faresay's current operations in the United Kingdom and to its planned expansion into the United States (the 50 states and the District of Columbia). Where a requirement differs between the UK and the US, or between US states, this is flagged. US-specific requirements take effect only on launch in the relevant state and are subject to validation by counsel and the clinical lead.

1.2.3 This Policy sits alongside and should be read with: the Therapist Agreement (therapist-agreement.md), the Crisis / Safeguarding Policy (crisis-safeguarding-policy.md), the Privacy Policy (privacy-policy.md), the Security & Data Protection Policy (security-data-protection-policy.md), and the Terms of Service (terms-of-service.md).

1.3 Status and ownership of this Policy

1.3.1 This Policy is owned by the Clinical Lead (see Section 3) and approved by [PLACEHOLDER: approving body — e.g. Faresay board / clinical advisory committee].

1.3.2 ⚠️ CLINICAL: This draft has been prepared without a qualified clinical lead in post. Every clinical standard, threshold, and exclusion in this Policy must be reviewed, corrected, and validated by a qualified clinical lead (and, where US-specific, by US-licensed clinical advisors) before the Policy is relied upon.


2. Definitions

In this Policy:


3. Governance Structure and Accountability

3.1 Principle of clinical leadership

3.1.1 ⚠️ CLINICAL: Clinical governance at Faresay must be led by a qualified clinician, not by commercial or product staff. Faresay will appoint a Clinical Lead who is professionally responsible and accountable for the matters in this Policy.

3.1.2 The Clinical Lead must hold a current, valid, unrestricted licence/registration with a relevant Professional Body and have appropriate seniority and experience in mental-health practice and clinical governance. [PLACEHOLDER: named Clinical Lead, qualifications, registration number.]

⚠️ COUNSEL / ⚠️ CLINICAL: In US corporate-practice states, the senior clinical authority may need to sit within (or be appointed by) the professional entity ("friendly PC"), not the MSO, to avoid the appearance of a non-clinical entity controlling clinical decisions. The reporting line and appointment mechanism for the Clinical Lead in the US structure must be designed with counsel.

3.2 Role of the Clinical Lead

3.2.1 The Clinical Lead is responsible for: owning and maintaining this Policy and related clinical standards; overseeing Practitioner onboarding, verification, and credentialing criteria (Section 4); defining scope-of-practice and exclusion criteria (Sections 6 and 15); overseeing quality assurance and outcome monitoring (Section 11); chairing or convening the Clinical Advisory Function; overseeing clinical incident review (Section 12) and the clinical complaints route (Section 13); and advising the business on clinical risk.

3.2.2 The Clinical Lead may delegate operational tasks but remains accountable for the clinical governance framework.

3.3 Clinical Advisory Function

3.3.1 ⚠️ CLINICAL: Faresay will establish a Clinical Advisory Function — a committee, panel, or set of named advisors — to support the Clinical Lead. Its composition, terms of reference, quorum, and meeting cadence are to be defined. [PLACEHOLDER: committee structure and members.]

3.3.2 The Clinical Advisory Function should, at minimum, include clinicians representing the main professional disciplines on the Platform (e.g. clinical/counselling psychology, psychotherapy, counselling, clinical social work) and, on US expansion, US-licensed clinicians familiar with the relevant state and professional standards. ⚠️ CLINICAL: confirm the appropriate disciplinary mix and whether independent (external) advisors are required.

3.3.3 Indicative responsibilities: reviewing and endorsing clinical standards and exclusion criteria; periodic case review and audit (Section 11); reviewing serious clinical incidents and trends (Section 12); and advising on emerging clinical risks and evidence.

3.4 Non-clinical roles

3.4.1 Faresay's trust-and-safety, onboarding/verification, support, data-protection, and engineering teams support clinical governance operationally (for example, by running verification checks and maintaining systems) but do not make clinical decisions. Clinical decisions about individual clients rest solely with the treating Practitioner.

3.4.2 A roles-and-responsibilities matrix is set out in Section 17.


4. Practitioner Onboarding and Verification

4.1 Principle

4.1.1 No Practitioner may deliver Clinical Services through the Platform until they have completed onboarding and verification and have been approved. Onboarding establishes that a Practitioner is appropriately qualified, licensed/registered, insured, and fit to practise.

4.2 Licensure / registration verification

4.2.1 UK. Faresay will verify that the Practitioner holds a current, valid, unrestricted registration or accredited membership with the relevant UK Professional Body (e.g. HCPC for practitioner psychologists; BACP, UKCP, or BABCP for counsellors/psychotherapists, as applicable). ⚠️ CLINICAL: confirm the minimum acceptable registers/accreditations Faresay will accept, and whether unaccredited counsellors are excluded.

4.2.2 US — licence in the client's state. A Practitioner must hold a current, valid, unrestricted licence to practise in the State in which the Client is physically located at the time of the session, consistent with the licensing requirements of that State's board. Faresay must verify licensure against the relevant State licensing board for each State in which the Practitioner is offered to clients.

⚠️ COUNSEL / ⚠️ CLINICAL: Telehealth licensure generally turns on where the client is located, not the practitioner. Per-State rules, exceptions, and any temporary/telehealth registrations must be confirmed by counsel and reflected in the platform's matching logic so a Practitioner can only be booked by clients in States where they are authorised.

4.2.3 Interstate compacts. Where a Practitioner holds authority under an applicable Compact, Faresay may verify and rely on that authority for the relevant States, subject to the compact's terms:

⚠️ COUNSEL: Compact participation, the scope of authority each compact grants (e.g. telehealth vs temporary in-person practice), member-State status, and the home-State requirement vary and change over time. Reliance on a compact for any given Client/State must be validated by counsel and re-checked as compacts and State participation evolve.

4.2.4 Verification must capture and store, at minimum: the licensing/registering body, licence/registration number, jurisdiction(s), licence type and scope, issue and expiry dates, and current standing. [PLACEHOLDER: verification provider / method — e.g. primary-source verification vendor.]

4.3 References

4.3.1 Faresay will obtain and review [PLACEHOLDER: number] professional reference(s) appropriate to the role. ⚠️ CLINICAL: confirm reference requirements (number, source, whether clinical-supervisor references are required).

4.4 Background / DBS checks

4.4.1 UK. Faresay will require an appropriate criminal-records / suitability check. ⚠️ COUNSEL / ⚠️ CLINICAL: confirm the correct DBS level for remote, non-regulated-activity mental-health work (basic vs standard vs enhanced), and whether the work meets the definition of "regulated activity" — this affects DBS eligibility and barred-list checks. Do not assert a DBS level until confirmed.

4.4.2 US. Faresay will require an appropriate background check consistent with applicable State and federal law. ⚠️ COUNSEL: background-check scope, consent (FCRA), and use of results vary by State and are subject to fair-chance / "ban-the-box" and adverse-action rules; confirm with counsel before defining the standard.

4.5 Professional indemnity insurance

4.5.1 Each Practitioner must hold and maintain professional indemnity / professional liability (malpractice) insurance appropriate to their discipline, jurisdiction(s) of practice, and the telehealth services delivered, at coverage limits no lower than [PLACEHOLDER: minimum limits]. Faresay will verify cover at onboarding and on renewal.

⚠️ COUNSEL / ⚠️ CLINICAL: Minimum coverage limits, whether telehealth and the relevant US States are within the policy's scope, and any requirement for Faresay to be named/additional insured must be set with counsel and the clinical lead. UK and US norms differ.

4.6 Fitness and declarations

4.6.1 At onboarding and on renewal, Practitioners must declare any past or pending fitness-to-practise proceedings, licence conditions/restrictions/suspensions, criminal matters, and material complaints or claims. Material non-disclosure may result in removal from the Platform.

4.7 Ongoing licence / sanction monitoring

4.7.1 Verification is not a one-time event. Faresay will operate ongoing monitoring of each Practitioner's continued eligibility, including:

4.7.2 On discovery of an expiry, sanction, restriction, or loss of insurance affecting a Practitioner's eligibility for any State/jurisdiction, Faresay will suspend the Practitioner's availability for the affected jurisdiction(s) pending review by the Clinical Lead, and manage any client-continuity-of-care implications under Sections 6, 12, and the Crisis / Safeguarding Policy (crisis-safeguarding-policy.md).


5. Standards of Care and Evidence-Based Practice

5.1 Practitioners are expected to deliver care that is consistent with current, recognised, evidence-based or evidence-informed practice for the presenting need and client population, within the limits of telehealth delivery.

5.2 Practitioners must comply with the ethical and practice standards of their Professional Body / licensing board (Section 18), including standards specific to remote/telehealth delivery.

5.3 ⚠️ CLINICAL: Confirm whether Faresay will reference or require adherence to specific clinical guidelines (e.g. NICE guidance in the UK; recognised US professional-body practice guidelines) or remain at the level of "consistent with the Practitioner's professional standards and competence." Avoid setting standards that could be read as Faresay directing clinical care.

5.4 Practitioners must keep their knowledge and skills current (see Section 10) and practise within their competence (Section 6).


6. Scope of Practice and Competence

6.1 Practising within competence

6.1.1 Practitioners must only provide Clinical Services that fall within their Scope of Practice — that is, services they are qualified, trained, competent, licensed/registered, and (where required) supervised to provide — and only with client populations and presentations they are competent to treat.

6.1.2 Practitioners must not work beyond their competence and must refer or signpost a Client elsewhere where the Client's needs fall outside the Practitioner's competence or outside what can be safely delivered on this Platform.

6.2 Presentations unsuitable for the Platform

6.2.1 ⚠️ CLINICAL: Faresay operates a cash-pay telehealth marketplace. Certain presentations and acuity levels are not appropriate for this setting and must be excluded from, or escalated out of, Platform-based care. These include (indicatively, to be finalised by the Clinical Lead):

6.2.2 The detailed clinical thresholds, screening, and the response when an excluded presentation is identified before or during care (including safe referral, escalation, and signposting to emergency services) are governed by the Crisis / Safeguarding Policy (crisis-safeguarding-policy.md), which this Policy cross-references and must be read with. ⚠️ CLINICAL: ensure the exclusion list here and the screening/escalation pathways in the Crisis / Safeguarding Policy are mutually consistent.


7.1 Before Clinical Services begin, the Practitioner is responsible for obtaining the Client's informed consent to treatment, consistent with the Practitioner's professional and legal obligations.

7.2 Informed consent should cover, at minimum: the nature, format, and limits of telehealth delivery; the likely approach and any material risks/benefits and alternatives; confidentiality and its limits (including duty-to-warn / safeguarding disclosures — see crisis-safeguarding-policy.md); how clinical records are kept and by whom; fees and the cash-pay model; and arrangements for crisis/out-of-hours situations and what to do in an emergency.

7.3 ⚠️ CLINICAL / ⚠️ COUNSEL: Informed-consent content and documentation requirements differ by jurisdiction and discipline (e.g. specific US State telehealth-consent statutes; capacity and consent for minors; emergency-contact and "patient location" attestations). Confirm jurisdiction-specific consent requirements and whether consent must be documented in a prescribed form.

7.4 Consent to clinical treatment (the Practitioner's responsibility) is distinct from consent to data processing by Faresay as a platform, which is addressed in the Privacy Policy (privacy-policy.md).


8. Clinical Record-Keeping Standards

8.1 The Practitioner / PC holds the clinical record

8.1.1 The clinical record is owned and held by the Practitioner (or, in a US corporate-practice structure, by the professional entity / "friendly PC" through which the Practitioner provides care) — not by Faresay. The Practitioner is the controller/custodian of the Clinical Record and is responsible for creating, maintaining, retaining, securing, and (where required) disposing of it in accordance with law and professional standards. See therapist-agreement.md clause 2.3.

8.1.2 Faresay processes Client and platform data as a technology provider as described in the Privacy Policy (privacy-policy.md) and Security & Data Protection Policy (security-data-protection-policy.md); this is distinct from holding the Clinical Record.

⚠️ COUNSEL: The controller/processor (UK GDPR) and covered-entity/business-associate (US HIPAA) characterisation of Faresay versus the Practitioner/PC for the Clinical Record and associated data must be confirmed with counsel, and may require a data processing agreement / business associate agreement. See security-data-protection-policy.md.

8.2 Minimum record-keeping standards

8.2.1 Practitioners must keep clinical records that are, at minimum:

8.2.2 [PLACEHOLDER: minimum retention periods] ⚠️ CLINICAL / ⚠️ COUNSEL: retention periods differ by jurisdiction, discipline, and client age (e.g. records for minors). Confirm per UK and per US State, and whether Faresay's platform tooling stores any clinical content (and if so, under what agreement).


9. Clinical Supervision and Continuing Professional Development

9.1 Practitioners must maintain clinical supervision and continuing professional development (CPD) consistent with the requirements of their Professional Body / licensing board, and must be able to evidence this on request.

9.2 ⚠️ CLINICAL: Some UK modalities/bodies require ongoing supervision (e.g. BACP's supervision requirement for counsellors); US requirements vary by State and licence type (including supervision requirements for pre-/associate-licensed clinicians). Confirm the minimum supervision and CPD standards Faresay will require, and whether pre-/associate-licensed practitioners are admitted at all and, if so, how supervision is evidenced.

9.3 Faresay does not act as the Practitioner's clinical supervisor and does not provide clinical supervision; responsibility for arranging adequate supervision rests with the Practitioner.


10. Quality Assurance and Outcome Monitoring

10.1 ⚠️ CLINICAL: Faresay will operate a clinical quality-assurance programme, overseen by the Clinical Lead and Clinical Advisory Function. The detailed design — including which measures, thresholds, and review cadences are appropriate and clinically valid — must be set by the clinical lead. Indicative components:

10.2 ⚠️ COUNSEL / ⚠️ CLINICAL: Outcome and case-review activity must be designed so it does not (a) involve Faresay in the practice of psychology/medicine or override clinical judgement, or (b) breach client confidentiality / data-protection law. Confirm the lawful basis, de-identification approach, and consent position for any clinical-data use with counsel; confirm clinical validity with the clinical lead.

10.3 Quality-assurance findings feed into Practitioner support, this Policy's periodic review (Section 16), and the risk register (risk-register.md).


11. Incident Reporting and Management

11.1 A clinical incident is any event in connection with Clinical Services that caused, or had the potential to cause, harm to a Client or another person — including safeguarding concerns, serious adverse events, suspected boundary or ethical breaches, data incidents affecting clinical information, and "near misses."

11.2 Practitioners and Faresay personnel must report clinical incidents promptly through [PLACEHOLDER: reporting channel / form]. Faresay will maintain an incident log and triage incidents to the Clinical Lead.

11.3 The Clinical Lead (with the Clinical Advisory Function for serious incidents) will ensure each incident is reviewed, immediate client safety is addressed, root causes and learning are identified, and corrective actions are tracked to completion. Trends are reported into quality assurance (Section 10) and the risk register (risk-register.md).

11.4 ⚠️ CLINICAL / ⚠️ COUNSEL: Certain incidents trigger external reporting or notification duties — for example to a regulator/licensing board, a safeguarding authority, an insurer, or (for data breaches) the ICO/affected individuals (UK) or under HIPAA breach-notification rules (US). The mandatory external reporting matrix must be confirmed per jurisdiction with counsel and the clinical lead. Crisis events (e.g. risk to life) are governed by the Crisis / Safeguarding Policy (crisis-safeguarding-policy.md).

11.5 Faresay will not retaliate against good-faith reporting of incidents or concerns.


12. Complaints Handling — Clinical Route

12.1 Faresay operates a clear route for Clients (and others) to raise concerns or complaints. Complaints are triaged into:

12.2 Clinical complaints will be acknowledged within [PLACEHOLDER: timeframe] and investigated by, or under the oversight of, the Clinical Lead, with the Practitioner given a fair opportunity to respond. Outcomes, learning, and any actions (including referral to fitness-to-practise processes where warranted) will be recorded and fed into incident management (Section 11) and quality assurance (Section 10).

12.3 Clients retain the right to complain directly to the Practitioner's Professional Body / licensing board, and Faresay will not obstruct this. Faresay will signpost the relevant body where appropriate. [PLACEHOLDER: complaints contact / address.]

12.4 ⚠️ COUNSEL: Confirm any regulatory complaint-handling requirements, timeframes, and record-keeping obligations applicable in the UK and relevant US States, and how clinical complaints interact with Faresay's terms (terms-of-service.md).


13. Suitability / Exclusion Criteria for Onboarding Clients

13.1 The Platform is suitable for adults (and, only if and where Faresay decides to serve them, minors — see below) seeking telehealth mental-health care for presentations that can be safely treated remotely on a cash-pay, planned-care basis.

13.2 ⚠️ CLINICAL: Client suitability screening and exclusion criteria must be defined by the clinical lead and aligned with Section 6 and the Crisis / Safeguarding Policy. Indicative exclusion/triage criteria for onboarding a Client:

13.3 Where a prospective or current Client is identified as unsuitable, Faresay and/or the Practitioner will signpost to more appropriate services and follow the escalation steps in the Crisis / Safeguarding Policy where risk is present.


14. Audit and Periodic Review

14.1 Faresay will periodically audit compliance with this Policy, including: a sample audit of Practitioner verification and ongoing-monitoring records (Section 4); review of incident and complaint logs and actions (Sections 11–12); and review of quality-assurance outputs (Section 10).

14.2 This Policy will be reviewed at least [PLACEHOLDER: e.g. annually], and additionally on any material change to law, regulation, professional standards, the business model, or following a serious incident. Review is led by the Clinical Lead and approved by [PLACEHOLDER: approving body].

14.3 Material clinical risks identified through audit and review are recorded in the risk register (risk-register.md).


15. Roles and Responsibilities Matrix

⚠️ CLINICAL / ⚠️ COUNSEL: Indicative only. The allocation below — particularly which responsibilities sit with the MSO vs the professional entity ("friendly PC") in US corporate-practice states — must be confirmed with the clinical lead and counsel. [PLACEHOLDER: named roles/owners.]

Area Practitioner Clinical Lead Clinical Advisory Function Faresay (non-clinical: trust & safety / ops / engineering)
Clinical decisions for individual clients Owns / accountable — (no individual-case direction)
This Policy & clinical standards Comply Owns / maintains Advises / endorses Supports operationally
Onboarding & verification (Section 4) Provide evidence Sets criteria; approves exceptions Advises Runs checks operationally
Ongoing licence/sanction monitoring (4.7) Keep credentials current; disclose Reviews flags; suspends eligibility Advises Runs monitoring; suspends availability operationally
Scope of practice / exclusions (Sections 6, 13) Works within competence Defines criteria Endorses Implements platform controls
Informed consent (Section 7) Obtains & documents Sets standard Advises Provides supporting tooling
Clinical records (Section 8) Owns / holds / retains Sets minimum standards Advises Provides secure platform tooling only
Supervision & CPD (Section 9) Arranges & evidences Sets minimum requirement Advises Verifies evidence
Quality assurance & outcomes (Section 10) Participate Owns programme Conducts case review Provides data tooling
Incidents (Section 11) Report; act on client safety Reviews / oversees Reviews serious incidents Logs; triages
Complaints — clinical (Section 12) Respond Oversees clinical route Reviews Triages; handles platform complaints
Audit & review (Section 14) Cooperate Leads Participates Supports

16. References to Professional and Ethical Frameworks

16.1 ⚠️ CLINICAL / ⚠️ COUNSEL: The lists below are indicative and must be confirmed and completed by the clinical lead and counsel — including which bodies/registers Faresay will recognise, and the correct, current standards for each discipline and jurisdiction.

16.2 United Kingdom (indicative).

16.3 United States (indicative).

16.4 Practitioners remain bound by the ethical and practice standards of the body that registers/licenses them, in addition to this Policy. Where this Policy and a Practitioner's professional standards conflict, the Practitioner must comply with their professional/legal obligations and raise the conflict with the Clinical Lead.



End of DRAFT v0.1. ⚠️ This document must be validated by a qualified clinical lead (and, for the points flagged ⚠️ COUNSEL, by counsel) before use.