Informed consent for individual session work with the Hearth Wellness Clinic
This is a consent to treat agreement between you and the Hearth Wellness Clinic (a dba of Hearth Science, Inc.). It outlines the nature of our work, its background, the basic construct of the modality, what you can expect from sessions, our expectations around your participation, and billing information. In summary, it lays out what you can expect from this process, and what we expect from you in order to maximize its benefit.
1. What is the Hearth Wellness Clinic?
The Hearth Wellness Clinic is a clinical team assembled by Hearth Science, Inc., which is a global pioneer in the neurobiology of connection and wellbeing. Hearth Science’s work is not currently a regulated industry in California. This is an emerging field and modality that Hearth Science, Inc., and our partners and advisors have been developing and refining, with the advice of nearly 100 mentors from 25 disciplines of wellbeing in 24 cultures for about 15 years, the practice model of which has been crowdsourced from 5,000 wellness professionals, and which we have field-tested with over 15,000 people in 50 countries. Our work has been featured in Psychology Today, and our Founder, Natureza Gabriel, has presented internationally on the work in medical, mental health, leadership, government, non-profit, and corporate settings. He was invited to teach the work to the faculty of the Stanford University School of Medicine. Our work is sustained and developed through a global collective eco-system of practitioners working collaboratively to advance its theory and praxis. The Hearth Wellness Clinic is one expression of this global eco-system.
Hearth Science is fundamentally a marriage of the neuroscience of healing and thriving with ancestral and Indigenous Lifeways. We work non-invasively, in real-time, with your embodied Autonomic Nervous System, which is the neural architecture of your mindbody connection. In our individual work we treat dysregulations of the autonomic physiology, which tend to express broadly in the category of stress-related disease, including anxiety, depression, gastro-intestinal distress, sleep difficulties, traumatic stress injuries, developmental traumas, and various forms of complex chronic illness. We also assist individuals in expanding their physiological co-regulation capacities and capacitizing their connection systems to stay online and regulated across an ever-wider range of adaptational challenge (e.g., elite performance) and to augment vitality.
As individual healing progresses, people tend to want to experience this greater vitality in the context of community, e.g., the hearth, which we understand as a form of culture repair, since modernity is predicated on undermining the sovereignty and equity of individuals based on their differences. For this reason we often transition clients from individual work to communities of practice when they achieve their initial wellness objectives.
Our individual and group work is combined with a proprietary learning platform that we built from scratch: the Restorative Practices Deep Learning platform. Our book Restorative Practices of Wellbeing, is the analog app to the deep learning platform that accompanies the individual healing work. Other books in our Connection Phenomenology series elucidate various aspects of our healing and transformational work, as applied to individuals, across difference, and with respect to culture and civilization generally.
2. How does The Hearth Wellness Clinic conceptualize healing and transformation?
Healing and transformation are both fundamentally non-linear processes, as they represent baseline shifts in the complex adaptive system that you know as yourself. Because of this non-linearity, a healing or transformative journey is likely to resemble a spiral more than a line. It is likely to include elements of mystery. Because it is often a spiral, there are times in a transformative journey when, relative to where you began, it may seem that you are going backwards. This is part of the process. The integration of new information, new ways of seeing, thinking, feeling, sense-making, organizing, and being, must be integrated throughout the totality of your consciousness to become durable. For this reason, it is important to hold a long view of this work, especially when we are addressing issues that have formed over long durations (which is often what brings people to see us in the clinic to begin with).
Your consciousness is expressed in your biology (the body you are wearing), as well as through the inner landscape of your experience of yourself. When people are ill, in a stress-induced manner, this tends to appear both in the body (pain, emotional unease, illbeing) and the inner landscape (sensations, emotions, thoughts, perceptions) and to be expressed through behavior. The common nexus of this bodily expression and your inner landscape is the Autonomic Nervous system (ANS), which is why our treatment model centralized autonomic physiology. The ANS is constantly in communication with all the other systems of your body, because a large part of what it does is monitor and modulate them. This is true of your immune system and endocrine systems in particular.
The ANS has three primary states, depending on whether or not we feel safe, in danger, or under life threat in the present moment. We illustrate these with primary colors, like this:
In the diagram above, blue represents safety, yellow danger, and red, lifethreat. If we feel safe at an embodied level, e.g., our center of gravity is in safety, the ANS can surface the connection system, which is the neurobiological foundation of wellbeing. If we do not feel safe, e.g., our center of gravity is in danger (yellow) or lifethreat (red) the ANS will surface various defensive platforms that may include fight or flight systems, as well as various forms of shutdown. These defensive systems may arise individually or in combination.
In our research we have identified thirteen distinct neural platforms arising from the ANS, which we are presently indexing through mathematical modelling. Our work is distinct in focalizing treatment on state-specific interventions, helping our clients develop precise identification of states (awareness), understanding in what context they arise, and identifying practices for alleviating them (addressing symptoms) as well as facilitating long-term neurogenic shifts in the autonomic baselines that give rise them. Here is a map of the full autonomic spectrum that our lab developed, and our visual design team illustrated.
As we learn new things, and engage in new practices, parts of our biological selves (skeletal, fascial, neural, immune, hormonal, etc. ), parts of our psychological selves (different internal parts, shadow, etc.), parts of our social selves (relationships with those close to us, family, social system), and parts of our ecological selves (relationships with the larger community of life) all begin to shift in complex ways. Because of the complexity of this process, it is useful to have guidance.
At the same time, Hearth Science work is founded upon the notion that you are a sovereign being, and that you are ultimately responsible for the process of shepherding your own awareness through the healing and transformational journey. No one can do this to you, or for you. Yet we can, however, witness and accompany you.
3. Hearth Science is, fundamentally, a relational modality.
This is expressed through your own relationship with yourself, and between you and your facilitators and practitioners, as well as the more-than-human world. Our interventions are outcome-oriented. Our objective is to help you restore functionality, and to shift your baseline, physiologically, from states of distress to states of wellbeing. The temporal arc of this process varies depending on what conditions have brought you to see us. Your facilitator may be individual, or part of a larger treatment team. In either case your facilitator will meet with you initially to form a diagnosis, and then prepare a tailored engagement plan. You can actively participate in the design of this to accommodate your cadence and preferences. In some places you maybe able to meet face-to-face with your facilitator. At other times the work is remote. Certain kinds of referrals within our network, for example to manual therapies, will require us having a practitioner affiliated with our work where you live. There are times when people travel to see practitioners in our network, or come to our eco-reserve in Northern California for healing or growth intensives.
4. Hearth Science is not medicine, functional medicine, or integrative medicine, though it may include such components in a referral network or tailored engagement plan, or your facilitator may be a medical practitioner.
Hearth Science is not psychotherapy or counseling, though it may include therapists or counselors, or your facilitator may be a therapist or counselor. Hearth Science does not address mental disorders as defined by the American Psychiatric Association, but rather structures an understanding of mind-body functioning scaffolded on centralizing autonomic physiology in the diagnosis and treatment of stress-related disease and increased wellbeing. Your Hearth Science sessions are not a substitute for counseling, psychotherapy, mental health care, physical health care or substance abuse treatment. Psychotherapy is a healthcare service and its primary focus is to identify, diagnose and treat nervous and mental disorders. Hearth Science is adjunct to mental health and functional/integrative medical treatment, and complements them, but is not a substitute for either one. Unless your facilitator is a licensed medical practitioner, or mental health practitioner, they are not making medical or mental health recommendations.
5. Hearth Science assumes the basic mental health of the client.
If you are dealing with active psychosis, or an active Axis I (Major Depression, Generalized Anxiety) or Axis II (Personality disorder) diagnosis, this is not the correct modality for you. Hearth Science is collaborative and relational.You can consider this a process of mutual accompaniment. Our work at times takes the form of individual engagements that have elements similar to coaching, and at times takes the form of work in communities of practice. Hearth Science is outcome-oriented. Our objective is to support your healing and transformation. We are interested in seeing you graduate from your current distress as soon as practically possible. At the same time, individuals respond in different ways, and at different depths, and with different cadences to our work. It is highly nuanced and tailored to the individual. So the duration and cadence of treatment may vary.
5. During our sessions…
your facilitator may invite you to engage in awareness practices, movement, or share stories. They may ask you to bring your attention to aspects of your inner experience, such as a thought, an emotion, or a sensation in a particular part of your body. They may invite you to move your attention to different parts of your body, or explore different sensory modalities (i.e., bring your attention to vision, or to what you can hear). They may suggest specific movements to you, or invite changes in posture. They may ask you to bring attention to your breath, or modulate it in some way. They are generally doing this as they track your ANS.
6. As you engage in this work, there is a risk that your symptoms may get worse before they get better.
Since we are working directly with the ANS, there is a risk that you may experience emotional discomfort. There is a risk that you may experience bodily sensations, vibrations, or changes in temperature that you find physically or emotionally uncomfortable.
7. Our deep learning platform is HIPPA compliant and bi-directionally encrypted.
Over the course of treatment, you may share information with our deep learning platform that could be construed as PHI (Protected Health Information). You are granting consent for this information to be shared with the platform, where it will be retained during our treatment, as well as the individual practitioners in our network who comprise your care team. This may include your practitioners, facilitators, mindbody educators, and curators. When treatment concludes you may request, should you so wish, that we remove it from our servers. You are granting consent for us to use your de-identified data to refine and improve our treatment interventions while your data is on our servers. You are granting consent for our practitioners and facilitators, while you are in treatment, to review your engagement with the learning platform, and your data, to monitor your progress toward treatment goals.
8. Our sessions will remain confidential unless
In order to effectively support you our team finds it necessary to consult with colleagues, mentors or advisors in which case we will ask for your permission to do so
We refer you to someone in our network, and in order to maximally support you it would be helpful to convey to them elements of your experience, case notes, or treatment plan, in which case we will ask for your permission to do so
you express a wish to harm yourself or others
you ask our team to share some element of our experience together with another practitioner or person of your choosing
9. Client Rights
You have the right to discontinue treatment at any time.
You, the client, are acknowledging:
10. I acknowledge that I have read, understand, and consent to Hearth Science individual treatment sessions.
11. I am aware of the dangers and the risks to my person involved in Hearth Science individual sessions.
I also understand that there are potential risks of which I may not presently be aware. Because of the dangers of participating in this activity, I recognize the importance and agree to fully comply with the applicable laws, policies, rules, and regulations, and any facilitator’s instructions regarding participation in this activity. I understand that Hearth Science, Inc. does not insure participants in the above-described activity, and that the Company has no responsibility or liability for injury resulting from this activity. I voluntarily elect to participate in this activity with knowledge of the danger involved, and I hereby agree to accept and assume any and all risks.
Waiver of Liability and Indemnification: In consideration for being allowed to voluntarily participate in the above-referenced activity, on behalf of myself, my personal representatives, heirs, next of kin, successors and assigns, I forever:
a) waive, release, and discharge Hearth Science, Inc. dba The Hearth Wellness Clinic, and its agencies, officers, and employees from any and all negligence and liability for my death, disability, personal injury, or claims of any nature which may hereafter accrue to me, and my estate as a direct or indirect result of my participation in the above referenced activity or event; and
b) agree to defend, indemnify, and hold harmless Hearth Science, Inc. dba The Hearth Wellness Clinic, its agencies, officers and employees, from and against any and all claims of any nature including all costs, expenses and attorneys’ fees, which in any manner result from participant’s actions during this activity or event.
This release, indemnification, and waiver shall be construed broadly to provide a release, indemnification, and waiver to the maximum extent permissible under applicable law.
I, the undersigned participant, affirm that I am at least 18 years of age and am freely signing this agreement. I have read this form and fully understand that by signing this form I am giving up legal rights and/or remedies which may otherwise be available to me regarding any losses I may sustain as a result of my participation. I agree that if any portion is held invalid, the remainder will continue in full legal force and effect.
Signed by, Hearth Science, Inc. (dba The Hearth Wellness Clinic)