CLIENT SERVICES AGREEMENT + RELATIONAL CONSENT FORM.

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CLIENT SERVICES AGREEMENT + RELATIONAL CONSENT FORM

Rupture Repair Sessions

This agreement outlines the expectations, boundaries, and nature of the work we will engage in together. By proceeding, you are agreeing to all terms listed below. Please read carefully.

1. NATURE OF THIS WORK

This is not psychotherapy. While I am a trained clinician, I am not operating in this space as your licensed therapist. This session will not include diagnosis, clinical treatment, insurance documentation, or medical records.

Instead, this is a space for relational repair, emotional clarity, and sacred witnessing. I will be offering care, presence, and intuitive support grounded in my clinical training and spiritual practice. This may feel therapeutic, but it is not therapy as defined by the legal or medical field.

Disclaimer: This work is not intended to diagnose, cure, or treat any condition. No medical, psychiatric, or psychological outcomes are guaranteed. By participating, you acknowledge full responsibility for your own choices, behaviors, and interpretations of the session experience.

2. CONSENT AND VOLUNTARY PARTICIPATION

  • You are participating voluntarily.

  • You may pause or stop at any time.

  • You are not obligated to continue after this session.

  • I may refer you to other providers if your needs exceed the scope of this work.

3. SCOPE AND LIMITATIONS

  • I am not offering therapy, legal advice, psychiatric care, or emergency crisis support.

  • I will not issue any clinical diagnoses or treatment plans.

  • If you are in acute crisis, please seek support from a licensed mental health professional or emergency resources.

4. LOCATION AND FORMAT

Sessions are held virtually (via Zoom or other secure platform), or in person at a predetermined location if explicitly arranged in advance. I do not operate out of a traditional office.

5. PRIVACY AND CONFIDENTIALITY

While this offering is not bound by HIPAA, your privacy is still treated with care and respect.

  • I will never share or disclose your personal information.

  • Any notes, intake forms, or birth data you provide are securely stored and used only for our work together.

  • Confidentiality may be broken if I am legally obligated to report imminent risk of harm to yourself or others, or known abuse of a vulnerable person. You will be informed if this occurs.

6. SPIRITUAL TOOLS AND BIRTH DATA

A significant part of my work includes the use of spiritual tools such as astrology, Human Design, and ancestral frameworks. Even if you do not believe in these systems, I strongly prefer that you provide your birth date, time, and city of birth. This information is used privately to deepen my understanding and enhance the clarity and alignment of our session.

You are always welcome to decline spiritual integration in-session if it feels uncomfortable to you—but I still ask that you share the information if possible. This is part of how I prepare, hold, and anchor the space.

Your data will never be shared and will only be used as part of my interpretive practice.

7. BOUNDARIES, COMMUNICATION, AND MUTUAL RESPECT

This is a relational space held with depth, precision, and care. That includes boundaries.

  • I am responsible to you, not for you.

  • I will not tolerate verbal aggression, projection, or boundary violations.

  • Any violation of boundaries may result in immediate termination of services, without refund.

  • I do not allow this space to be used to scapegoat or displace unprocessed emotions onto me.

  • I will hold emotional weight with you, but not at the expense of my own safety or capacity.

Communication boundaries: I am not available for ongoing emotional processing between sessions unless explicitly arranged. Please allow up to 48 hours for email or message responses. If you are in crisis, please reach out to appropriate emergency or licensed supports.

8. SCHEDULING, CANCELLATIONS, AND REFUNDS

  • Cancellations must be made at least 48 hours in advance to receive a full refund.

  • No-shows or same-day cancellations will be charged in full, unless otherwise discussed.

  • For certain services (such as crisis support or Safe Passage), where I may have cleared my schedule or turned down other work to be present, no refund will be issued.

All payment terms will be clearly communicated prior to the session. Payment is required in advance unless other arrangements have been made.

9. ACKNOWLEDGMENT AND AGREEMENT

By checking the boxes below, you are confirming that you have read and understood the nature of this offering and are entering this space with full awareness and consent.

By checking the boxes, you acknowledge that:

  • You understand this is not therapy and no clinical diagnosis or treatment is being provided.

  • You are participating voluntarily and are aware of your rights and responsibilities.

  • You understand that spiritual and interpretive tools (including astrology and Human Design) are a part of this practice, and you are willing to provide your birth data even if you choose not to engage those tools in session.

  • You agree to uphold the energetic, emotional, and professional boundaries of this space.

  • You understand that any violation of boundaries may result in immediate termination of services.

  • You understand and agree to the cancellation and refund policy as outlined.

  • You understand that your information will be held privately and securely, and used only for the purposes of this work.