Review, sign, save, and print your consent and waiver forms — everything in one place. Your typed name is your electronic signature.
Please note: Healing the Black Woman is a health advocacy and holistic wellness coaching practice, not a licensed medical or mental-health provider. These documents are provided as templates and may need review by an attorney licensed in your state. Nothing here is medical or legal advice. Signing below does not establish a physician-patient or therapist-client relationship.
5 documents · sign & save to your portal
What Healing the Black Woman provides, what it does not, and the terms of our working relationship.
Healing the Black Woman provides health advocacy, medical navigation, holistic wellness coaching, group healing circles, workshops, and educational resources. These services are designed to support, educate, and empower you — not to diagnose or treat.
Our services are not a substitute for medical diagnosis, treatment, or advice from a licensed physician; are not psychotherapy, counseling, or psychiatric care; and are not emergency or crisis services. Always consult a qualified licensed provider for medical or mental-health concerns.
You remain in full control of your own healthcare and life decisions at all times. Your advocate/coach will not make medical decisions on your behalf and will not replace the judgment of your licensed providers.
Information you share is treated as confidential. Exceptions exist where the law requires disclosure — including imminent risk of serious harm to yourself or others, suspected abuse or neglect of a child or vulnerable adult, or a valid court order.
Fees, cancellation, and refund terms are described in our Cancellation & Refund Policy below and apply to all sessions, circles, workshops, and retreats.
You may withdraw consent and end services at any time. Withdrawal does not affect the confidentiality obligations already described.
Type your full legal name below — this is your electronic signature. Save it to your portal and/or print it to take with you.
How your information is protected — including within group settings.
What you share in one-on-one coaching and advocacy sessions is held in confidence, subject to the legal exceptions described in the Informed Consent (harm to self/others, abuse or neglect, court order).
Group settings involve shared disclosure. We ask every participant to honor the confidentiality of others and agree not to repeat or record what others share. We cannot guarantee that every participant will keep that commitment, so please share only what you are comfortable having within the circle.
Personal and health information is stored securely and accessed only by those who need it to provide services. See our Privacy Policy for details.
Type your full legal name below — this is your electronic signature. Save it to your portal and/or print it to take with you.
Permission to coordinate your care with your providers and support team.
I authorize Healing the Black Woman to communicate with the individuals and/or organizations listed above regarding my care (e.g., physicians, specialists, therapists, or family members).
This authorization is voluntary. I may revoke it in writing at any time, except to the extent action has already been taken in reliance on it. This authorization expires one (1) year from the date of signature unless otherwise specified.
Type your full legal name below — this is your electronic signature. Save it to your portal and/or print it to take with you.
Consent for sessions conducted by phone or video.
Some services are provided by phone or video. By participating, you consent to telehealth-style communication and understand the following:
• Technology may occasionally fail or interrupt; we will make reasonable efforts to reschedule if a session is disrupted.
• You are responsible for being in a private, safe space on your end; confidentiality cannot be fully guaranteed on public or shared devices/networks.
• In an emergency during a virtual session, standard crisis protocols apply (see Crisis Resources below); virtual sessions are not appropriate for emergency care.
Type your full legal name below — this is your electronic signature. Save it to your portal and/or print it to take with you.
Consent regarding photography and recording at in-person events.
Workshops and retreats may be photographed or recorded for promotional and educational purposes. By attending, you consent to the use of your image/likeness in such materials unless you notify us in writing before the event that you wish to opt out.
We will honor opt-out requests to the extent reasonably possible and will never use recordings of sensitive disclosures for marketing without your separate written consent.
Type your full legal name below — this is your electronic signature. Save it to your portal and/or print it to take with you.
3 documents
Voluntary participation and release for coaching, circles, workshops, and retreats.
I understand that participation in coaching, group healing circles, workshops, retreats, and related activities is voluntary, and that wellness and personal-growth activities can involve physical, emotional, and psychological responses.
To the fullest extent permitted by law, I voluntarily assume all risks associated with my participation, and I release, hold harmless, and discharge Healing the Black Woman and its facilitators, employees, and agents from any claims arising from my participation, except for claims arising from gross negligence or willful misconduct.
This waiver does not obligate Healing the Black Woman to provide medical or emergency care. In an emergency, I authorize the organizers to seek emergency medical assistance on my behalf at my own expense.
Type your full legal name below — this is your electronic signature. Save it to your portal and/or print it to take with you.
Clear statement that our services are not medical or mental-health treatment.
Healing the Black Woman provides coaching, advocacy, education, and wellness support. These services are not medical advice, diagnosis, or treatment, and are not psychotherapy or counseling.
Do not disregard, delay, or discontinue any treatment prescribed by a licensed physician or mental-health professional because of anything shared in our services. Always consult your own qualified providers regarding any medical or mental-health condition, diagnosis, or treatment.
Nothing on this website or in our services is intended to establish a physician-patient or therapist-client relationship.
We are not a crisis service. Here is where to get immediate help.
Healing the Black Woman is not a crisis or emergency service and cannot provide immediate assistance. If you or someone you know is in immediate danger or having a medical or psychiatric emergency, call 911 or go to your nearest emergency room.
• Suicide & Crisis Lifeline — call or text 988
• Crisis Text Line — text HOME to 741741
• National Suicide Prevention Lifeline — 1-800-273-8255
• SAMHSA (substance use & mental health) — 1-800-662-4357
• National Domestic Violence Hotline — 1-800-799-7233 or text START to 88788
If you are outside the United States, contact your local emergency number or crisis service.
4 documents
Cancellation, rescheduling, no-show, and refund terms.
Please provide at least 24 hours' notice to cancel or reschedule a one-on-one session. Sessions cancelled with less than 24 hours' notice, or missed without notice, may be charged the full session fee at our discretion.
Unless otherwise stated, event registrations are non-refundable within 7 days of the event start date. Refunds requested more than 7 days in advance may be issued less any non-recoverable processing or deposit fees.
Email Kiara.S@healingtheblackwoman.com with your name, event or session, and request. We will confirm receipt within 2 business days.
What personal information we collect, how we use it, and your rights.
We collect information you provide directly — such as your name, email address, phone number, date of birth, and health/wellness information you choose to share through booking, intake, or profile forms — as well as basic usage data (e.g., pages visited) collected automatically.
We use your information to provide and coordinate services, schedule and confirm appointments, communicate with you, process payments, and improve our services. We do not sell your personal information.
We use reasonable administrative, technical, and physical safeguards to protect your information. No method of transmission or storage is 100% secure, and we cannot guarantee absolute security.
We share information only as necessary to provide services (e.g., payment processors, scheduling tools), as required by law, or with your authorization (see Release of Information).
You may request access to, correction of, or deletion of your personal information by contacting Kiara.S@healingtheblackwoman.com. We will respond within a reasonable timeframe and as required by applicable law.
Terms governing use of this website and booking.
By using this website or booking services, you agree to these Terms of Service and our Privacy Policy.
Content on this site and in our services is for informational and educational purposes only and is not medical, psychological, or legal advice.
Appointments are subject to availability. Payment terms, cancellation, and refunds are governed by our Cancellation & Refund Policy.
All site content, materials, and resources are owned by Healing the Black Woman and may not be reproduced or redistributed without written permission.
To the fullest extent permitted by law, Healing the Black Woman is not liable for indirect, incidental, or consequential damages arising from use of this site or our services.
These terms are governed by the laws of the state in which Healing the Black Woman operates, without regard to conflict-of-law principles.
How your information is used and disclosed, and where HIPAA does and does not apply.
Healing the Black Woman is a wellness coaching and health advocacy practice — not a licensed healthcare provider, health plan, or healthcare clearinghouse. As such, we are generally not a HIPAA 'covered entity.' We nevertheless treat your personal and health information as confidential and follow privacy best practices.
When we coordinate your care with covered providers (for example, as your personal representative in medical navigation), we handle any protected health information we receive in accordance with HIPAA-compliant authorizations and confidentiality obligations.
You have the right to request access to and correction of your information, to request confidential communications, and to ask us to limit how we use or share your information. To exercise these rights, contact Kiara.S@healingtheblackwoman.com.
If a breach of unsecured personal or health information occurs, we will notify affected individuals as required by applicable law.
Questions about your forms or privacy? Email Kiara.S@healingtheblackwoman.com