EMBODIED MIND HEALTH LEADERSHIP™

                   EMBODIED MIND HEALTH LEADERSHIP™

                       PARTICIPANT INFORMED CONSENT.

                         PROGRAM ACKNOWLEDGMENT.

                            SAFETY AGREEMENT.

                      Please read this document carefully.

Embodied Mind Health Leadership™ was created with compassion, respect, and a commitment to supporting learning, self-awareness, personal agency, embodied well-being, and leadership development.

The purpose of this agreement is to clearly explain the nature and limitations of the program, the facilitator’s qualifications and scope of practice, the possible risks of participation, the participant’s

responsibilities, and the procedures that may be followed if a safety concern arises.

Participation is voluntary. 

Please ask questions about any part of this agreement that you do not understand before signing.

1. PROGRAM FACILITATOR AND PROFESSIONAL ROLE

The program is facilitated by Jessica Martinez, M.A. is an adult educator, embodied leadership

facilitator, mental-health advocate, and trained yoga and meditation teacher.

Her background includes:

● A Master of Arts degree in Education

● Multiple teaching credentials

● Extensive adult education experience

● Yoga and meditation teacher training

● Decades of professional and volunteer involvement in mental-health advocacy, education, peer support,

and community service

● Personal lived experience informing a recovery-oriented and trauma-informed perspective

The facilitator is not acting as a physician, psychologist, psychiatrist, psychotherapist, licensed clinical

mental health counselor, clinical social worker, marriage and family therapist, nurse, emergency responder,

or other licensed healthcare provider through this program.

Nothing in this program should be interpreted as representing that the facilitator holds a clinical license that

she does not hold.

2. EDUCATIONAL AND EXPERIENTIAL NATURE OF THE PROGRAM

Embodied Mind Health Leadership™ is an adult education, personal development, wellness, and leadership

program.

Program activities may include:

• ● Educational presentations
• ● Gentle movement and body-awareness practices
• ● Breathing and relaxation practices
• ● Meditation and mindfulness
• ● Guided reflection and self-inquiry
• ● Journaling
• ● Leadership-development exercises
• ● Group discussion
• ● Peer connection
• Exploration  of meaning, values, identity, purpose, and contribution.

The program may offer practices that support stress awareness, resilience, self-understanding, personal growth, embodied presence, and leadership development. However, the program is not represented as curing, preventing, diagnosing, managing, or treating any medical or mental-health condition.

3. THIS PROGRAM IS NOT CLINICAL OR MEDICAL TREATMENT

Embodied Mind Health Leadership™ does not provide:

● Psychotherapy

● Clinical counseling

● Medical treatment

● Psychiatric treatment

● Psychological testing

● Diagnosis

● Clinical assessment

● Suicide-risk assessment

● Crisis intervention

● Medication advice

● Treatment planning

● Trauma processing

● Rehabilitation services

● Substance-use treatment

● Case management

● Emergency services

Participation does not create a therapist-client, doctor-patient, counselor-client, or other licensed clinicaL treatment relationship.

The program is not a replacement for care from a physician, licensed mental-health professional, physical therapist, emergency provider, or other qualified healthcare professional.

Participants should not delay, discontinue, or change medical treatment, psychotherapy, medication, or other professional services because of anything discussed or practiced in this program.

Questions about medication, diagnosis, physical symptoms, psychological symptoms, or treatment should be directed to an appropriately licensed healthcare provider.

4. TRAUMA-INFORMED APPROACH

The program is designed to be trauma-informed. A trauma-informed approach emphasizes principles such

as safety, trust, transparency, peer support, collaboration, empowerment, voice, and choice.

Being trauma-informed does not mean that the facilitator is providing trauma therapy or clinical trauma

treatment.

Participants will generally be encouraged to:

● Make choices about their participation

● Modify or decline an activity

● Keep their eyes open during meditation

● Change position or movement

● Take a break

● Leave an exercise when necessary

● Refrain from sharing personal information

● Ask for clarification

● Respect their physical and emotional limits

No participant is required to disclose a traumatic event, psychiatric diagnosis, medical history, or other deeply personal experience to participate. Although the program strives to create a respectful environment, no group setting can be guaranteed to feel

completely safe or comfortable for every person at every moment.

5. POSSIBLE EMOTIONAL AND PHYSICAL RISKS

The participant understands that meditation, body awareness, movement, breathing exercises, self-reflection, group discussion, and leadership exercises may affect people differently.

Possible experiences may include:

● Temporary emotional discomfort

● Sadness, grief, anger, fear, embarrassment, or vulnerability

● Increased awareness of difficult thoughts, memories, sensations, or emotions

● Fatigue, dizziness, discomfort, or physical strain

● Feeling emotionally activated, overwhelmed, or unsettled

● Discomfort related to group discussion or interpersonal differences

● Unexpected emotional or bodily responses

The facilitator cannot predict how particular participant will respond.

Participants are responsible for monitoring their own comfort and well-being and for stopping or modifying any activity that feels unsafe, painful, destabilizing, or inappropriate.

Participants with medical conditions, injuries, pregnancy, balance difficulties, chronic pain, psychiatric conditions, or other health concerns are encouraged to consult appropriate licensed professional beforeparticipating in movement, meditation, breathing, or other experiential practices.

6. PARTICIPANT CHOICE AND RIGHT TO WITHDRAW

Participation is voluntary.

The participant may:

● Decline any exercise

● Decline to speak or share

● Request a modification

● Take a break

● Leave a session

● Withdraw from the program

The participant does not need to explain or disclose personal information in order to decline an activity.

The facilitator may also pause or discontinue a participant’s involvement when the program appears unsuitable for the person’s immediate needs, when safety is at risk, when group guidelines are repeatedly violated, or when the participant appears to require a level of clinical or crisis support that the program cannot provide.

When appropriate, the participant may be encouraged to seek evaluation or assistance from a licensed professional before returning.

7. MENTAL-HEALTH CRISES, SUICIDE, SELF-HARM, AND EMERGENCIES

Embodied Mind Health Leadership™ is not a crisis-response, suicide-prevention, or emergency service.

The facilitator and program cannot provide continuous monitoring, emergency supervision, clinical suicide-risk assessment, hospitalization decisions, or immediate intervention outside scheduled program activities.

The program website, registration form, email address, telephone number, voicemail, text messages, social-media accounts, online meeting platform, and group communications must not be used as substitutes for emergency or crisis services.

A participant experiencing any of the following should obtain immediate professional assistance:

● Thoughts of suicide or self-harm

● An intention, plan, or preparation to harm oneself

● Thoughts or intentions of harming another person

● An inability to remain safe

● Severe confusion or loss of contact with reality

● A medical or psychiatric emergency

● Abuse, violence, or immediate danger

● Symptoms requiring urgent medical attention

In the United States, a person experiencing suicidal crisis or emotional distress may call or text 988 to reach

the 988 Suicide & Crisis Lifeline.

When there is immediate danger or an urgent medical emergency, call 911 or go to the nearest emergency

department.

The participant agrees not to rely exclusively on the facilitator or the program for crisis assistance, suicide

prevention, emergency care, or personal safety.

8. SAFETY DISCLOSURES AND FACILITATOR RESPONSE

The facilitator is not providing clinical suicide-risk assessment or treatment. However, if a participant communicates information suggesting a serious or immediate danger to the participant or another person, the facilitator may take reasonable steps intended to support safety. Depending upon the circumstances, these steps may include:

● Pausing the participant’s involvement in the session

● Encouraging the participant to contact 988, 911, a licensed provider, or another emergency resource

● Asking the participant to contact a trusted support person

● Contacting the participant’s emergency contact

● Requesting assistance from emergency responders

● Sharing reasonably necessary information with emergency personnel

● Consulting a qualified professional or legal advisor

● Ending or postponing the participant’s involvement in the program

The facilitator does not promise that she will be able to identify, predict, prevent, or respond successfully to

every crisis, act of self-harm, suicide attempt, suicide, medical event, or emergency.

Providing emergency-contact information does not create a duty for the facilitator to provide continuous supervision, monitoring, clinical care, or emergency response.

9. EMERGENCY CONTACT AND LOCATION INFORMATION

Because a safety concern can arise during an in-person or online program, participants are asked to provide

accurate identifying and emergency information.

The requested information may include:

● Legal name

● Preferred name

● Date of birth or confirmation that the participant is at least 18

● Home address

● Telephone number

● Email address

● Emergency-contact name

● Emergency-contact relationship

● Emergency-contact telephone number

● The participant’s physical location during an online session, when reasonably requested for emergency

purposes

This information is requested so that the facilitator can:

● Communicate about registration and scheduling

● Identify the participant

● Contact a designated support person when reasonably necessary

● Provide location information to emergency personnel when a serious and immediate safety concern arises

● Administer the program responsibly

The participant agrees to provide truthful and current information and to notify the facilitator when essential

contact information changes.

10. PRIVACY AND HANDLING OF PERSONAL INFORMATION

The facilitator will make reasonable efforts to safeguard personal information and use it only for legitimate

program, administrative, communication, safety, legal, or emergency purposes.

Information may be disclosed when:

● The participant provides permission

● Disclosure is reasonably necessary to respond to a serious safety concern

● Disclosure is required by law, subpoena, court order, or other legal process

● Disclosure is necessary to consult an attorney, insurer, emergency responder, or other appropriate

professional

● The information is necessary for program administration or payment processing

Embodied Mind Health Leadership™ is an educational program and may not be a healthcare provider or organization governed by the Health Insurance Portability and Accountability Act, commonly known as HIPAA.

Therefore, participants should not assume that communications with the facilitator carry the same legal confidentiality protections as communications with a licensed therapist, physician, or other healthcare provider.

Page 5Participants are encouraged to avoid sending highly sensitive medical or psychiatric information through ordinary email, text messaging, social media, or other communication systems that may not be encrypted.

11. GROUP PRIVACY AND CONFIDENTIALITY

Participants are expected to respect the privacy of other group members.

Participants agree not to:

● Record a session without express written permission

● Photograph or capture images of other participants

● Share another participant’s personal story or identifying information

● Post information about another participant on social media

● Distribute private group messages, screenshots, or recordings

● Contact another participant in a harassing, intrusive, or unwanted manner

The facilitator will ask participants to honor these expectations. However, because participants are not

necessarily licensed professionals and are not under the facilitator’s complete control, the facilitator cannot

guarantee that every participant will maintain confidentiality.

Participants should share only information they are comfortable sharing in a group environment.

12. ONLINE PARTICIPATION

When sessions occur online, participants understand that technology can create additional privacy and

safety limitations.

Possible risks include:

● Internet interruption

● Unauthorized access

● Accidental recording

● Someone being present in another participant’s environment

● Loss of privacy through email, video platforms, messaging, or shared devices

● Difficulty locating or assisting a participant during an emergency

Participants are encouraged to join from a private location, use headphones when appropriate, protect their

passwords, and avoid recording sessions.

During an online session, the facilitator may ask a participant to confirm the physical address or location

from which the participant is attending. This information may be used if emergency assistance becomes

reasonably necessary.

13. NO GUARANTEE OF RESULTS

The facilitator makes no promise or guarantee regarding any particular outcome.

Participation may or may not improve:

● Stress

● Emotional well-being

● Physical comfort

● Relationships

● Leadership abilities

● Employment

Recovery

● Confidence

● Health

● Personal development

● Quality of life

Results vary according to many factors beyond the facilitator’s control. The participant understands that testimonials, personal stories, examples, educational material, or descriptions of possible benefits do not constitute promises or guarantees of individual results.

14. PARTICIPANT RESPONSIBILITIES

By participating, the participant agrees to:

● 1. Take reasonable responsibility for personal choices, health, safety, and well-being.

● 2. Seek licensed medical, psychological, psychiatric, or other professional assistance when needed.

● 3. Inform the facilitator of limitations that may affect safe participation, without being required to disclose

unnecessary details.

● 4. Stop or modify an activity that causes pain, significant distress, dizziness, destabilization, or other

concerning symptoms.

● 5. Not attend while intoxicated or impaired by alcohol, illegal substances, or misuse of medication.

● 6. Avoid disruptive, threatening, discriminatory, abusive, or harassing conduct.

● 7. Respect the privacy, dignity, boundaries, identities, and experiences of other participants.

● 8. Not use the program as a replacement for emergency, clinical, or medical care.

● 9. Use emergency services rather than waiting for a response from the facilitator when urgent assistance

is neede d.

● 10. Notify the facilitator when the participant believes the program is causing significant distress or is no

longer appropriate.

15. PHYSICAL MOVEMENT AND MEDITATION ACKNOWLEDGMENT

Some program activities may involve gentle movement, stretching, changes in posture, standing, sitting ,lying down, breathing practices, relaxation, visualization, or meditation. 

The participant understands that all physical activity carries some risk of discomfort or injury.

The participant agrees to:

● Work within personal limitations

● Avoid movements that feel unsafe or painful

● Use appropriate supports when needed

● Consult a healthcare professional when uncertain about physical participation

● Tell the facilitator when a modification is needed

● Stop immediately if experiencing severe pain, faintness, breathing difficulty, chest pain, or other

concerning symptoms

The participant understands that the facilitator cannot diagnose injuries or determine whether an exercise is

medically appropriate for a particular condition.

16. PERSONAL BOUNDARIES AND VOLUNTARY SHARING

Participants may discuss personal experiences, but the program does not require detailed disclosure of trauma, diagnosis, hospitalization, abuse, medical history, or other private information.

Participants are encouraged to speak from their own experience and to avoid advising, diagnosing, treating,

rescuing, or attempting to counsel another participant.

The facilitator may redirect a conversation that becomes clinically inappropriate, unsafe, overly graphic,

discriminatory, or inconsistent with the educational purpose of the program.

17. REFERRAL OR DISCONTINUATION

The program may not be appropriate for every person at every time.

The facilitator may recommend that a participant obtain additional professional support or discontinue

participation when:

● The participant requires clinical treatment or crisis intervention

● Participation appears to be contributing to serious destabilization

● The participant presents an immediate or substantial safety concern

● The participant repeatedly violates program boundaries

● The participant disrupts the physical or emotional safety of the group

● The facilitator determines that the participant’s needs exceed the program’s educational scope

Such a recommendation is not a diagnosis or clinical determination. It is a boundary concerning what the program can responsibly provide.

18. ASSUMPTION OF ORDINARY PROGRAM RISKS

The participant acknowledges that voluntary participation in educational discussion, meditation, movement,

self-reflection, online communication, and group activities involves ordinary and foreseeable risks, including

emotional discomfort, physical discomfort, interpersonal disagreement, and limitations of technology.

The participant voluntarily chooses to participate with an understanding of the nature and limitations of the

program.

Nothing in this agreement is intended to release or excuse conduct that cannot legally be waived, including

conduct for which liability cannot lawfully be excluded.

19. LIMITATION OF THE AGREEMENT

This document is intended to clarify expectations, informed consent, program boundaries, and participant

responsibilities.

It does not guarantee that injury, distress, crisis, self-harm, suicide, medical emergency, or other adverse

event will not occur.

It does not create a clinical duty, treatment relationship, fiduciary relationship, or guarantee of rescue, monitoring, protection, or outcome. No written agreement can eliminate rights or responsibilities that cannot legally be waived under applicable

law.

20. QUESTIONS AND VOLUNTARY CONSENT

The participant confirms that:

● I have read this agreement carefully.

● I have had the opportunity to ask questions.

● I understand that this is an educational and experiential program rather than psychotherapy or

healthcare.

● I understand that the facilitator is not acting as my therapist, physician, or licensed mental-health

provider.

● I understand that the program does not provide crisis response or suicide prevention.

● I understand that I am responsible for obtaining appropriate professional and emergency assistance.

● I understand that participation may involve emotional and physical discomfort.

● I understand that I may decline an activity or withdraw from the program.

● I agree to respect the privacy and boundaries of other participants.

● I voluntarily consent to participate.

PARTICIPANT INFORMATION

Full legal name: __________________________________________

Preferred name: __________________________________________

Date of birth: ____________________________________________

Pronouns, if participant wishes to provide them:

____________________________________________________________

Home address:

____________________________________________________________

____________________________________________________________

Telephone number: ________________________________________

Email address: ___________________________________________

EMERGENCY CONTACT

Emergency-contact name:

____________________________________________________________

Relationship to participant:

____________________________________________________________

Emergency-contact telephone number:

____________________________________________________________

Alternate telephone number, if available:

____________________________________________________________

I authorize the facilitator to contact this person when the facilitator reasonably believes that doing so is

necessary in response to a serious concern regarding my immediate safety, health, or well-being.

Participant initials: __________

OPTIONAL HEALTH AND ACCESS INFORMATION

Participants are not required to provide detailed medical or psychiatric histories. However, they may

voluntarily identify information that would help the facilitator offer reasonable educational modifications or

accessibility support.

Mobility, sensory, communication, or accessibility needs:

____________________________________________________________

____________________________________________________________

Page 9Movement, meditation, breathing, or other practices I should avoid or modify:

____________________________________________________________

____________________________________________________________

Other information I voluntarily choose to provide:

____________________________________________________________

____________________________________________________________

Providing this information does not create a medical or clinical treatment relationship.

PARTICIPANT SIGNATURE

By signing below, I affirm that I have read and understood this agreement and voluntarily consent to

participate under the terms described above.

Participant printed name:

____________________________________________________________

Participant signature:

____________________________________________________________

Date: ______________________

Program or course name:

____________________________________________________________

Program beginning date: __________________________________

FACILITATOR ACKNOWLEDGMENT

Facilitator name: Jessica Martinez, M.A., RYT-500

Facilitator signature:

____________________________________________________________

Date: ______________________