Consent & Policy Forms

Trauma-Informed | Somatic | Attachment-Based Care
Phoenix, Arizona
Phone: (602) 610-8250 | Email: info@healingservant.com

Effective Date of this Notice: December 2025
(You may request a paper copy at any time, even if you receive this electronically.)

Welcome

Welcome — I’m glad you’re here.

Before we begin with policies and practical details, I want you to hear this clearly:

You are not too much. You are not broken. You are not beyond help.

Every part of you makes sense in the context of your life, and every part of you is welcome here.

This document is your Notice of Privacy Practices (HIPAA), Informed Consent for Treatment, and Practice Policies for 2026. It is written to be readable, relational, and transparent. You are encouraged to take your time, pause, ask questions, and notice what your body needs as you read.

Therapy works best when there is clarity, choice, and safety. This form exists to support those values.

PART A — INFORMED CONSENT FOR TREATMENT

1) About Me & My Approach

My name is Kristi M. Estrada. I am a Licensed Professional Counselor-Supervisor (LPC-S), Nationally Certified Counselor (NCC), and Somatic Experiencing Practitioner (SEP) and founder of The Healing Servant Team.

My work is grounded in:

• Trauma-informed care
• Attachment repair and relational safety
• Somatic (body-based) therapy and nervous-system regulation
• Expressive and relational approaches
• Optional, client-guided integration of Christian faith only when welcomed by you

Healing here is collaborative. I do not “fix” you. We listen together — to your story, your body, your patterns, your protective strategies, and your strengths — and we build safety from the inside out.

Nature of the Professional and Therapeutic Relationship
The therapeutic relationship is intended to be a safe, supportive, and professional relationship focused on your care. Because therapy involves highly personal, vulnerable, and often emotionally meaningful material, it is important that this relationship remain professional in nature for your well-being and protection.

To preserve the integrity of treatment and reduce the risk of confusion, conflicts of interest, or harm, I do not enter into personal, social, financial, or other non-therapeutic relationships with clients that could impair my objectivity, clinical judgment, or ability to provide ethically appropriate care. This includes maintaining professional boundaries in person, by phone, electronically, virtually, and through social media.

If we encounter one another in public, I will not initiate contact in order to protect your privacy. If you choose to greet me, I will respond briefly and respectfully, while protecting your confidentiality and the professional nature of our work.

This relationship is collaborative and caring, but it is not a friendship, family relationship, mentorship, business partnership, or social relationship. Maintaining this clear professional container supports safety, trust, and effective treatment.

2) Consent for Therapy Services (Voluntary + Ongoing)

By engaging in services, you are voluntarily consenting to participate in behavioral health treatment. Services may include (but are not limited to):

• Individual therapy
• Couples/family therapy (when appropriate and scheduled)
• Group therapy (when offered and applicable)
• Somatic/body-based interventions
• Attachment-focused and trauma-informed interventions
• Expressive/creative/relational modalities (as clinically appropriate)
• Coordination of care and/or consultation with other professionals (as appropriate)

You understand:

• Therapy is a collaborative process.
• Results cannot be guaranteed.
• Growth can include both relief and discomfort.
• You may pause, slow down, or stop any intervention at any time.
• Your consent is ongoing and may be withdrawn at any time.
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If you withdraw consent or stop treatment, we will discuss next steps, risk reduction, and referral options when appropriate.

3) Purpose of Treatment

Therapy is intended to support your mental, emotional, relational, and nervous-system health. Goals may include (but are not limited to): improved regulation, reduced symptoms, increased self-worth, healthier boundaries, trauma recovery, improved relationships, and improved life functioning.

4) General Procedures, Benefits, Limitations, and Risks

1. Procedures

Therapy may involve:

• Talking and reflecting on experiences, patterns, relationships, emotions, beliefs
• Skills for regulation, boundaries, communication, and coping
• Tracking body sensations and nervous-system responses
• Exploring attachment patterns, grief, trauma impacts, and protective strategies
• Resourcing, stabilization, titration (going slowly), and repair-based work
• Between-session supports (always optional and collaborative)

1. Potential Benefits

Benefits may include improved emotional regulation, greater insight, symptom reduction, improved relationships, increased resilience, and improved functioning.

1. Limitations and Risks

• Outcomes cannot be guaranteed.
• You may experience temporary increases in emotion, fatigue, vulnerability, grief, or sensitivity as you process stress or trauma.
• You may encounter discomfort when exploring painful material.
• We will pace carefully and prioritize safety and stabilization.

5) Treatment Planning + Your Participation

You have the right to:

• Participate in developing and reviewing your treatment plan
• Request revisions as needs change
• Ask questions about methods, pacing, and alternatives
• Request an explanation of treatment approaches and options, as clinically appropriate

Treatment planning is intended to be collaborative, clinically tailored to your needs, and completed and updated in accordance with applicable documentation requirements and standards of care.

6) Refusal/Withdrawal and Possible Consequences

You may refuse or withdraw from treatment or any specific intervention at any time. If you discontinue, possible consequences can include unresolved symptoms, reduced support during stressors, and loss of continuity of care. We will collaborate to reduce risk and support a thoughtful transition when possible.

7) Supervision and Professional Consultation (Quality of Care)

To support ethical practice and clinical excellence:

• I may consult with other licensed clinicians as needed.
• Consultation uses the minimum necessary information and protects identifying details whenever possible.
• If services are provided by a supervised clinician (associate/intern), the supervising clinician may review the case and documentation for training and quality of care.

8) Records, Documentation, and Session Content

Behavioral health care requires documentation. Records may include: intake information, diagnosis (when applicable), treatment plans, progress notes, coordination of care, and billing/administrative records.

Communications related to your treatment, welfare, safety, and professional services may be preserved in the clinical record in accordance with applicable law and board requirements.

Psychotherapy notes (if kept separately from the medical record) are treated differently under HIPAA and generally are not released without your authorization except as permitted by law.

9) Recording, Observation, and Third Parties

• No session is audio-recorded or video-recorded without your separate written consent signed and dated in advance.
• No third party (student/trainee/observer/other clinician) will observe or participate without your separate written consent signed and dated in advance.
• You may decline any recording/observation request without penalty to your care.

PART B — SOMATIC & BODY-BASED THERAPY CONSENT

10) What Somatic Therapy Is

Somatic therapy focuses on how trauma, stress, and emotion live in the body. This may include attention to:

• Breath
• Muscle tension/relaxation
• Posture
• Movement or stillness
• Sensations (warmth, heaviness, tightness, tingling, numbness)

You are always in control of your body and your pace. Somatic work is consent-based and titrated (we go slowly enough to stay safe).

1. Touch (Optional; Never Required)

Somatic therapy does not require physical touch.

If touch is ever considered clinically helpful, it will only occur:

• After explicit discussion beforehand
• With clear, specific consent
• With your right to decline or stop at any time
• With alternatives always available (self-touch, grounding objects, pillows, movement, posture options)

If you consent to touch, it will be professional, clinically appropriate, and focused on regulation/support. You may revoke consent at any time, including mid-session.

1. Somatic Work May Involve Discomfort

Somatic work can bring up emotions or body responses. We will pace carefully and prioritize stabilization over intensity. Your safety and dignity guide the process.

PART C — MINORS, PARENTS/GUARDIANS, AND FAMILY RIGHTS

11) Consent for Minors: Parent/Guardian Consent + Minor Assent

For clients under age 18, treatment generally requires the consent of a parent or legal guardian unless otherwise permitted by applicable law. When developmentally appropriate, the minor will also be invited to provide assent, meaning an age-appropriate agreement to participate in treatment.

Therapy with minors is most effective when expectations are clearly discussed at the outset, including parent involvement, communication boundaries, privacy, confidentiality, and safety planning.

12) Custody and Legal Authority to Consent

If parents are divorced, separated, or share legal decision-making authority, the parent or guardian seeking services affirms that they have the legal authority to consent to treatment and agrees to provide any relevant court orders, parenting plans, or legal decision-making documents upon request.

When parents share legal decision-making, it is best practice for written consent from both parents or legal guardians to be obtained unless legal documentation establishes otherwise. Even when one parent has sole legal decision-making authority, the practice may consider the ethical, clinical, and safety implications of proceeding with the consent of only one parent and may seek consultation when appropriate.

Unless legal documentation states otherwise, parent rights of access to records and treatment information may apply under Arizona law and applicable regulations. A developmentally appropriate balance between parental involvement and the minor’s privacy will be discussed at the beginning of treatment and revisited as needed.

13) Parent Access to Information: Privacy With Care

Parents/guardians often have legal rights to access a minor’s health information. At the same time, therapy can be most effective when the minor has a developmentally appropriate sense of privacy.

We will discuss a balanced approach, which may include:

• General updates for parents (themes, goals, ways to support)
• Protecting the minor’s private disclosures when clinically appropriate
• Clearly defined limits of confidentiality (see Part F and mandated reporting section)

If safety concerns arise, we will prioritize safety and involve parents/guardians and/or appropriate authorities as required.

PART D — TELEHEALTH + IN-PERSON SERVICES

14) In-Person Services

In-person sessions occur in a professional clinical setting. Reasonable accommodations may be requested when possible (lighting, seating, pacing) to support nervous-system safety.

15) Telehealth Consent

Telehealth may occur via interactive audio/video and other secure electronic methods. If you are physically outside Arizona during a telehealth session, services may need to be rescheduled, modified, or declined depending on the laws and regulations of the jurisdiction where you are located.

1. Telehealth Risks and Limitations

You understand telehealth includes additional risks/limitations, including:

• Confidentiality risks of electronic communication (no system is risk-free)
• Technology failures (dropped calls, lag, power/internet issues)
• Limits to what can be observed/assessed through a screen
• Telehealth may be inappropriate in certain crises or when higher level of care is needed

1. Your Responsibilities for Privacy and Safety

You agree to:

• Use a private location where you cannot be overheard
• Use headphones when possible
• Not drive during sessions
• Notify the clinician if anyone enters your space
• Keep your camera positioned to support clinical work (when video is used)

1. Identity Verification

We may verify identity at the start of sessions (name/DOB and/or additional steps when needed).

1. Location and Emergency Planning (Each Telehealth Session)

For each telehealth session, we may document:

• Mode of session (video/audio)
• Your physical location during session
• Your local emergency contact and/or local emergency resources for that location

1. Technology Failure Plan

If we are disconnected:

1. clinician attempts reconnection
2. if unsuccessful, clinician contacts you via the agreed backup method (phone/portal)
3. if safety risk is suspected and you cannot be reached, we may contact your emergency contact and/or local emergency services based on your location

1. Telehealth Is Not Crisis Care

This practice is not a 24-hour crisis service. If you need immediate help:

• Call 911
• Call 988 (Suicide & Crisis Lifeline)
• Go to the nearest emergency room

PART E — GROUP SERVICES (IF APPLICABLE)

16) Group Therapy Informed Consent (Expanded)

If you participate in group therapy, you understand:

1. What Group Therapy Is

Group therapy is a clinical service where members work on shared goals in a structured therapeutic setting. Group may include psychoeducation, skills practice, processing, and relational/somatic exercises, depending on the group’s purpose.

1. Voluntary Participation

Participation is voluntary. You may choose your level of sharing, may pass on any activity, and may discontinue group participation at any time. We will support a thoughtful transition when possible.

1. Confidentiality in Group: Strongly Expected, Not Guaranteed

Confidentiality is essential and is reviewed regularly. However, because other members are not bound by HIPAA in the same way, confidentiality cannot be fully guaranteed.

By joining group, you agree to:

• Keep other members’ identities and personal information private
• Not share names, stories, screenshots, or identifying details outside group
• Not record group sessions in any way (audio/video/screen capture)
• Attend from a private space if participating by telehealth

1. Limits of Confidentiality Still Apply

The clinician must follow mandated reporting and safety laws (see Part F). Group members may also disclose information that triggers mandated reporting obligations.

1. Group Boundaries and Safety Agreements

To protect emotional and relational safety, you agree to:

• Treat others with respect and avoid shaming, harassment, threats, or intimidation
• Allow differences in experience and pacing
• Avoid substance intoxication during group
• Follow group structure and facilitator direction
• Participate in repair if relational rupture occurs (as clinically appropriate)

1. Between-Session Contact With Group Members

Members are encouraged to be thoughtful about contact outside group. If members connect outside group, it is at their own choice and risk. The practice is not responsible for relationships outside sessions. We will discuss boundaries as needed.

1. Attendance, Fees, and Termination From Group

Groups may have specific policies for attendance, late arrivals, cancellations, and fees. The clinician may pause or end a member’s participation if:

• safety cannot be maintained
• confidentiality is repeatedly violated
• behavior disrupts group integrity
• higher level of care is indicated

If group services are ended, referrals may be provided as appropriate.

PART F — NOTICE OF PRIVACY PRACTICES (HIPAA) + LIMITS OF CONFIDENTIALITY

17) Our Legal Duties

We are required by law to:

• Maintain the privacy of your PHI
• Provide this Notice
• Follow the terms of the Notice in effect
• Notify you as required by law if a breach of unsecured PHI occurs

If privacy practices materially change, we will update this Notice and provide access to the updated version.

18) How We May Use and Disclose PHI (Without Your Authorization)

1. Treatment

To provide, coordinate, or manage your care, including consultation and coordination with other providers involved in treatment.

1. Payment

For billing, claims, eligibility verification, and payment activities.

1. Health Care Operations

For quality improvement, training/supervision, auditing, and practice management.

1. As Required by Law / Safety / Public Protection

We may disclose PHI as required by law, including:

• Risk of serious harm to self or others
• Suspected abuse/neglect of a child, elder, or vulnerable/dependent adult
• Court orders, subpoenas, or other lawful mandates
• Health oversight activities permitted by law

When disclosure is required, we disclose only the minimum necessary when applicable.

19) Limits of Confidentiality

Confidentiality is foundational — and there are legal limits. Depending on circumstances and applicable law, disclosure may be required or permitted when:

• you are at imminent risk of harming yourself
• you are at imminent risk of harming someone else
• there is suspected abuse or neglect of a child, elder, or vulnerable/dependent adult
• a court orders records or testimony (see subpoena/court section)
• other specific legal requirements apply

We will make every reasonable effort to discuss required disclosures with you when clinically appropriate and safe to do so.

20) Subpoenas, Court Involvement, and Legal Proceedings

Therapy works best when it is protected from legal entanglement. If you become involved in legal proceedings:

• A subpoena alone may not be sufficient for release; a court order or your written authorization may be required depending on circumstances.
• If records are requested, we may require time to review, consult, and respond appropriately.
• Court appearances, deposition time, record preparation, and related legal services may be billed at a separate professional rate (provided upon request), unless prohibited by law.

21) Uses/Disclosures Requiring Written Authorization

Most disclosures outside treatment/payment/operations require your written authorization, including:

• sharing with family members (unless legally authorized)
• employers, attorneys, schools, or other third parties (unless required by law)

You may revoke an authorization in writing at any time, except to the extent action has already been taken based on it.

22) Your Rights Regarding PHI

You have the right to:

• Request access to your records (with some legal exceptions)
• Request amendments/corrections
• Request confidential communications (alternate address/email)
• Request restrictions/limits (we may not always be able to agree, but we will consider your request)
• Receive an accounting of certain disclosures
• Receive a copy of this Notice at any time
• File a privacy complaint without retaliation

Requests should be submitted in writing through the portal or to info@healingservant.com. Reasonable fees may apply as permitted by law.

23) Privacy Complaints and Board Concerns

1. Privacy Complaints

If you believe your privacy rights have been violated, you may file a complaint with:

• The practice (contact below), and/or
• The U.S. Department of Health & Human Services (HHS)

You will not be penalized for filing a complaint.

Privacy Contact:
Kristi M. Estrada, LPC-S, NCC, SEP
602-610-8250 | info@healingservant.com

1. Board Concerns

Arizona Board of Behavioral Health Examiners
1740 W Adams St, Suite 3600, Phoenix, AZ 85007 | 602-542-1882

PART G — COMMUNICATION, BOUNDARIES, AND PRACTICE POLICIES

24) Communication Methods and Response Times

To protect your privacy, support clear boundaries, and maintain accurate records, the client portal is the preferred method for secure communication whenever available.

Text messaging may be used for limited administrative purposes such as scheduling, rescheduling, confirmations, and logistical coordination. Texting is not intended for therapy, crisis support, or ongoing clinical processing.

Email is not guaranteed to be secure. If email is used, you understand there may be privacy risks. Portal messaging is preferred whenever possible.

Messages are not monitored 24 hours a day, 7 days a week. Typical response time for non-urgent administrative communication is within 1–2 business days, excluding weekends, holidays, vacations, and other times the practice is closed.

Electronic communication can easily create misunderstandings regarding availability, urgency, tone, and boundaries. For that reason, the practice may redirect clinical matters to a scheduled session, the client portal, or another more appropriate format.

Any communication related to your treatment, welfare, safety, clinical care, or professional services may be documented in your clinical record as required by applicable law and board rules.

This practice is not an emergency service. If you are in crisis or need immediate support, call 911, call 988, or go to the nearest emergency room.

25) Emergencies and After-Hours Care

This practice is not a 24-hour crisis service. Please identify additional supports outside therapy. In an emergency:

• Call 911
• Call 988
• Go to the nearest emergency room

26) Social Media, Online Presence, and Public Encounters

To protect confidentiality, privacy, and professional boundaries, I do not accept friend requests, follow requests, or personal social media connections from current clients through personal social media accounts or platforms.

I do not search for clients on social media or other online platforms unless there is a compelling clinical, legal, or safety-related reason to do so, and, if that ever becomes necessary, the rationale and any relevant actions may be documented in the clinical record.

If you choose to view public professional content associated with the practice, please do so with awareness that public engagement may affect your privacy. To protect confidentiality, the practice does not acknowledge publicly whether someone is or was a client.

Caution is also important with former clients. Even after therapy ends, the practice remains mindful of the potential for boundary concerns, conflicts of interest, and harm arising from personal online connections.

If we encounter one another in public, I will not initiate contact in order to protect your privacy. If you greet me, I will respond briefly and respectfully without discussing confidential information in public.

27) Fees, Billing, Insurance, and Payment Policies

1. Fees (unless otherwise agreed in writing)

• Initial intake: $180
• Individual session: $150
• Couples/family: $150
• Group: $100/hour (when applicable)

1. Payment Timing

Payment is due at the time of service unless otherwise arranged in writing. If using insurance, you are responsible for copays/coinsurance/deductibles as applicable.

1. Late Cancellations / No-Shows

If not canceled/rescheduled at least 24 hours in advance, a $50 late cancellation/no-show fee may be charged (unless prohibited by payer contract or law). Exceptions may be made for emergencies at clinician discretion.

1. Returned Payments / Collections

A fee may be charged for returned payments. If an account is sent to collections, you may be responsible for reasonable costs as permitted by law.

1. Refund Policy

Refund requests must be submitted in writing. The practice will respond within a reasonable timeframe (example: within 10 business days). Refunds are handled consistent with services rendered and applicable laws/policies.

28) Participation Expectations and Therapy “Container”

Therapy is most effective when sessions are attended consistently and when we communicate about barriers. If attendance becomes inconsistent or treatment is not clinically appropriate at this level of care, we may discuss referrals, pause services, or transition care.

29) Termination, Transfers, and Continuity of Care

You may end therapy at any time. The clinician may also initiate termination when:

• treatment is no longer beneficial
• a different level of care is needed
• boundaries, safety, or participation expectations cannot be maintained
• fees remain unpaid after reasonable attempts to resolve
• the clinician is unable to continue services (illness, relocation, etc.)

When possible, termination includes discussion of next steps and referrals.

PART H — AI USE DISCLOSURE

30) Limited Use of AI-Assisted Tools (Administrative Support Only)

This practice may use limited Artificial Intelligence (AI)-assisted tools in certain administrative and documentation-support functions. AI is not a therapist, does not provide treatment, and does not replace clinical judgment, diagnosis, assessment, or decision-making. All clinical decisions, interpretations, treatment planning, and documentation remain the responsibility of the clinician.

Examples of possible limited AI-supported functions may include:

• formatting templates,
• organizing administrative or practice workflow,
• assisting with non-clinical drafting, and
• when applicable, assisting with documentation support.

If AI-assisted tools are used in a way that involves treatment-related or documentation-related material, the clinician remains fully responsible for reviewing, editing, and approving all final documentation for accuracy, appropriateness, and ethical compliance.

The practice will make reasonable efforts to use privacy-conscious, secure, and clinically appropriate tools and to limit the information disclosed to the minimum necessary for the intended purpose. No AI tool is permitted to independently diagnose, advise, or make treatment decisions for clients.

31) Your Choice Regarding AI Use

You have the right to ask questions about whether and how AI-assisted tools are used in this practice.

If AI-assisted tools are used in treatment-related documentation support, you may decline such use. Declining AI-assisted support will not affect your access to care. The practice will document your preference and will continue services without AI-assisted documentation support when reasonably available and clinically appropriate.

If the practice ever adopts a more specific AI-enabled documentation feature within its electronic health record or another platform, you may be provided with an additional consent or acknowledgment form describing that feature, including any available options to accept or decline its use.

32) Protection of Confidentiality in Relation to AI

The practice remains responsible for safeguarding your confidentiality and privacy. Any use of AI-assisted tools must remain consistent with applicable confidentiality, privacy, ethical, and documentation obligations. The clinician will review all AI-assisted outputs and will not rely on AI-generated content without clinical review and professional judgment.

PART I — CONSENT & ACKNOWLEDGMENT

By signing/acknowledging this document, you confirm:

• You have read and understood this Notice of Privacy Practices, Informed Consent for Treatment, and Practice Policies
• You had the opportunity to ask questions and receive answers
• You consent to treatment as described
• You understand somatic therapy consent, including that touch is optional and never required
• You understand telehealth risks and requirements (including location verification and emergency planning for telehealth)
• You understand privacy rights and limits of confidentiality
• You understand group confidentiality expectations and that confidentiality cannot be fully guaranteed in group settings
• You understand there is no recording/observation without separate written consent