Before Your First Session
Confidentiality Agreement & Client Consent Form
Emotional Wellness with Jackie — A Program of S.A.F.E., Inc.
Please read the full agreement below carefully. Complete the form at the bottom to provide your electronic signature. A copy will be sent to your email address, and Jackie will countersign and return the fully executed agreement to you.
S.A.F.E., INC. · Sisters Anointed for Encouragement
EMOTIONAL WELLNESS WITH JACKIE
A Program of S.A.F.E., Inc.
CONFIDENTIALITY AGREEMENT AND CLIENT CONSENT FORM
PURPOSE OF THE PROGRAM
Emotional Wellness with Jackie is a supportive program offered through S.A.F.E., Inc. (Sisters Anointed for Encouragement).
Led by Jacqueline R. Jones, Co-Founder, Vice President, and Emotional Wellness Advisor, this program provides a compassionate, confidential environment where women can explore their emotions, develop self-awareness, strengthen resilience, and work toward healthier relationships.
This program reflects S.A.F.E., Inc.'s mission of encouraging women through faith-based support, personal development, and community connection.
Emotional wellness advising provides nonclinical emotional support and education.
It does not include mental health diagnosis, psychotherapy, medical treatment, or emergency services.
Participation is voluntary. Clients may decline questions or discontinue participation at any time.
RESPECTING YOUR PRIVACY
Information shared during private emotional wellness sessions will be treated as confidential and used to support the client's emotional wellness journey.
Session discussions and notes will not routinely be shared with S.A.F.E. leadership, members, family, or other individuals.
Sharing information beyond the limited administration described below requires the client's specific written authorization unless a confidentiality exception applies.
LIMITS OF CONFIDENTIALITY
Confidentiality is not absolute.
Information may need to be disclosed when required by applicable law, including legally required reports of suspected abuse or neglect or a legally enforceable demand for records.
Information may also be disclosed as permitted or required by law to address a serious and imminent threat to safety.
When appropriate and lawful, the advisor will discuss a disclosure with the client and limit it to what is necessary.
This agreement does not promise legal privilege.
REGISTRATION THROUGH S.A.F.E.
Emotional Wellness with Jackie operates as a program of S.A.F.E., Inc.
Clients may register through the S.A.F.E. website or mobile application.
Jacqueline R. Jones and designated S.A.F.E. administrators may receive necessary administrative information, including:
- Client name
- Contact information
- Requested appointment
- Booking confirmation
- Necessary payment status
Access to this information will be limited to individuals responsible for these administrative functions.
Private session conversations and notes will remain separate from S.A.F.E.'s general membership records and routine communications.
Clients should not submit sensitive personal information through public forms or shared messages.
COMMUNICATION AND RECORDS
Email, text messages, and website forms may carry privacy risks.
These communication methods should primarily be used for scheduling and general inquiries.
Sensitive personal discussions should take place during the agreed private session.
Records must be protected and accessible only to authorized individuals.
No audio recording, video recording, or AI transcription will occur without separate informed consent.
SESSION FEES AND PAYMENT
Questions during S.A.F.E. group sessions are welcome at no additional charge.
Dedicated, extended one-on-one emotional wellness sessions with Jacqueline R. Jones are available to members and nonmembers.
The $25 deposit is credited toward the total $50 session fee.
Payments are processed through S.A.F.E., Inc.'s designated Zeffy payment system.
Payment timing, cancellation, and refund terms will be confirmed and disclosed before payment.
Services are privately paid and are not billed to insurance.
Any additional fees must be disclosed and agreed upon before payment.
CLIENT ACKNOWLEDGMENT
- I understand Emotional Wellness with Jackie is a program of S.A.F.E., Inc.
- I understand Jacqueline R. Jones serves as the program's Emotional Wellness Advisor.
- I understand the nature of the emotional wellness services being offered.
- I understand these services are nonclinical and do not replace licensed mental health or medical care.
- I understand the confidentiality protections and their limitations.
- I understand that necessary administrative information may be processed through S.A.F.E., Inc.
- I understand my private session information will not be shared for marketing, testimonials, or general S.A.F.E. activities without separate authorization.
- I understand the session fee and payment arrangements.
- I have had an opportunity to ask questions before signing.
Electronic Signature
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