Heart Mind Body, LLC

Informed Consent for Treatment

Client Name: ____________________________________
Date of Birth: ____________________
Date: ____________________

Welcome to Heart Mind Body

Welcome to Heart Mind Body (HMB). Our work is grounded in a holistic, trauma-informed approach that recognizes the connection between the mind, body, and emotional experience.

This document is designed to help you understand the nature of services, your rights, and important policies. Please read carefully and ask any questions before signing.

Nature of Services

HMB provides mental health services which may include:

• Provided by PMHNP-BC or Licensed Counselors as appropriate:
• Psychiatric evaluation
• Medication management
• Psychotherapy (talk therapy)
• Trauma-informed care, including Trauma Storming™ framework
• Integrative and holistic approaches
• Life Coaching
• Neurofeedback

Treatment is collaborative and may evolve over time based on your needs and goals.

Trauma-Informed Framework

At HMB, we understand that:

Trauma is not a personal failure.
It reflects how your nervous system adapted to experiences that were overwhelming.

Our approach (including Trauma Storming™) views emotional responses as adaptive, dynamic processes, not pathology. This means:

• You will never be judged for your experiences
• Your pace will be respected
• Safety and stabilization are prioritized

Risks and Benefits of Treatment

Potential Benefits

• Symptom relief
• Improved coping and emotional regulation
• Increased self-awareness
• Improved relationships and functioning

Potential Risks

• Emotional discomfort when discussing difficult experiences
• Temporary increase in distress
• Unexpected memories or feelings
• Dysregulation toward provider when experiencing a trigger

You may stop or modify treatment at any time.

Confidentiality

Your information is protected under HIPAA and state law.

Information will NOT be shared without your written consent except in the following situations:

• Risk of harm to yourself or others
• Suspected abuse or neglect of a child, elder, or vulnerable adult
• Court order or legal requirement
• Medical emergencies

If disclosure is required, we will make reasonable efforts to discuss this with you when appropriate.

Communication

HMB may use the following methods to communicate with you:

• Phone calls
• Voicemail messages
• Text messages
• Email

Important: These methods may not be fully secure.

You may choose to opt in or decline any of these communication methods.

Emergency & Crisis Policy

HMB is not a 24/7 emergency service.

If you are experiencing a crisis:

• Call 911, or
• Go to your nearest emergency room, or
• Call/text 988 (Suicide & Crisis Lifeline)

Do not rely on email or text for urgent needs.

Client Responsibilities

You agree to:

• Provide accurate and complete information
• Participate actively in treatment
• Follow agreed-upon treatment plans when possible
• Communicate openly about concerns

Provider Responsibilities

Your provider agrees to:

• Offer competent, ethical, and professional care
• Maintain appropriate boundaries
• Protect your confidentiality
• Collaborate with you in your treatment

Right to Refuse or Withdraw

You have the right to:

• Refuse any treatment or intervention
• Request a different provider
• Withdraw from treatment at any time

Telehealth

If services are provided via telehealth:

• You understand there may be risks to privacy
• You agree to participate from a private location when possible
• You understand technology disruptions may occur

Questions

You are encouraged to ask questions at any time. Your understanding and comfort with treatment are important.

Consent to Treatment

By signing below, you acknowledge that:

• You have read and understand this document
• You have had the opportunity to ask questions
• You voluntarily consent to receive treatment at Heart Mind Body

Client Signature: ____________________________________
Date: ____________________

Parent/Guardian (if applicable): __________________________
Date: ____________________

Provider Signature: ____________________________________
Date: ____________________