top of page

Participant Forms
 

To help create a safe, supportive, and personalized experience, I ask all new participants to complete a few intake forms before our first session. These forms help me better understand your goals, communication preferences, support needs, and any accommodations that will help you feel comfortable throughout our work together.

Everything you share is treated with care and confidentiality. Please complete the forms at your own pace, and don't worry if you're unsure how to answer every question—we can always revisit them together.
 

Forms may include:
 

  • Participant Intake Form

  • Goals & Vision Questionnaire

  • Support Services Agreement

  • Informed Consent

  • Payment Authorization

  • Emergency Contact Information

  • Communication Preferences

  • Accessibility & Accommodation Requests
     

My goal is to make this process as simple, welcoming, and accessible as possible so we can begin building support that honors your unique needs

This agreement is between you (the participant) and Savía Support, Rosemarie Gastelum (Chita). By signing below, you acknowledge that you understand and agree to the terms of this agreement.

Accessibility & Communication Preferences

I understand that session recording is optional and not required to receive services. If I consent, the recording will be used only to support accurate note-taking, kept confidential using secure HIPAA-level privacy practices, will not be shared, and will be permanently deleted after notes are completed on the same day.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Month
Day
Year

Payer Agreement

Savía Support (Raíz Systems)

By signing below, the Payer acknowledges that they have read, understand, and agree to the terms outlined in this agreement.

Delivery Address

The Payer agrees to be financially responsible for all professional support services provided by Savia Support•, raíz systems to the Participant.

Please check selections
Please check selection below
The Payer understands that Savia Support•, Raíz Systems provides non-clinical, trauma-informed support services. These services are not psychotherapy, counseling, or medical treatment.
Please check selection below
The Payer agrees to maintain respectful and clear communication regarding scheduling, payments, and program participation.
Please check selection below
The Payer acknowledges that they have had the opportunity to ask questions and voluntarily agree to the terms of this agreement.
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Electronic Communication Consent

Savía Support•, raíz systems uses electronic communication to support our work together. Please read and sign this consent form.

Methods of Communication
Email
Phone Call
Messaging (SMS)
Video Call (Zoom + Google Meet)
Other
Please select options below
Please select options below
Please select options below
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
bottom of page