Applicant Information

Session Type

Personal Statement

If selected for a discounted or pro bono session, I agree to provide reasonable documentation of financial need if requested by Kalea Wellness.

Consent, Acknowledgements, and Releases

By submitting this application, I acknowledge and agree to the following:

1. I understand this application is for a single discounted or pro bono session only, which may include an initial phone consultation and/or a comprehensive assessment (CA).

2. I understand that no guarantee of continued treatment or long-term services is provided through this program.

3. I understand that submitting this application does not guarantee selection, and that one applicant is selected each calendar month at the sole discretion of Kalea Wellness.

4. I understand that I may reapply for future consideration, but priority is given to those who have not previously received support through this program.

5. I consent to Kalea Wellness reviewing this application and contacting me regarding my eligibility or application status.

6. I understand that this is a confidential form, and my information will be handled with appropriate privacy and discretion under HIPAA and applicable healthcare laws.

7. I understand that Kalea Wellness reserves the right to approve or deny applications at its sole discretion, and that all decisions are final.

8. I understand that receiving a discounted or pro bono session does not guarantee any specific diagnosis, therapeutic outcome, or improvement in condition.

9. I understand that this program covers only services provided directly by Kalea Wellness and does not include services provided by independent therapists or external providers.

10. I understand that Kalea Wellness does not supervise, manage, or assume responsibility for the clinical care, actions, billing practices, or outcomes provided by independent therapists affiliated with or practicing at Kalea Wellness.

11. I understand that Kalea Wellness may modify, pause, or discontinue this program at any time without prior notice.

12. I understand that this application is not intended for urgent or emergency medical or mental health needs. If I am in crisis, I will call 911 or seek help from emergency services.

13. If selected for clinical services, I consent to evaluation by a licensed provider. I understand that participation does not establish a long-term physician-patient relationship unless explicitly agreed upon in writing.

14. To the extent permitted by law, I release Kalea Wellness, its staff, and affiliates from liability related to the outcomes of this discretionary session, including emotional responses, perceived lack of improvement, or dissatisfaction.

15. I authorize Kalea Wellness to store and process my application electronically in accordance with HIPAA-compliant data security standards.

16. I affirm that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false information may disqualify me from current or future participation.

17. Any dispute arising from this application or participation in this program shall be governed by the laws of the State of Nevada, and venue for any such disputes shall be exclusively in the courts located in Clark County, Nevada.