Welcome — and thank you.

🔐 Mindful Passions Referral Provider Consent & Info Form

This form collects essential details for inclusion in the MPI Referral Provider Directory, which is used in two key ways:

🌀 How We Use This Directory

Client Intake
When new clients join Mindful Passions, they can optionally select a referring provider. This helps us track how clients find us and supports client-practitioner continuity.
📍 If you consent, your name may appear in a client-facing dropdown under “Who referred you to MPI?”

Practitioner Referrals
We use this directory to match clients with trusted, scope-aligned providers when additional support is needed — including therapy, medical care, energy work, and more.
📍 We refer based on stated specialties, capacity, and relational fit — honoring boundaries on both sides.

This form helps us:

  • Ensure consent before listing your name

  • Keep your information current

  • Understand your ideal clients and referral preferences

✅ What Consent Means Here

By completing this form and selecting “Yes” below, you consent to:

  • Being listed in our private database directory for referral purposes

  • Potentially appearing in a dropdown on our client intake form under “Referring Provider”

  • Receiving client referrals that are aligned with your scope, values, and stated preferences, and which you have no obligation to accept

You may update or withdraw your information at any time — just email us.

🌀 Your referral relationships matter.

MPI is a trauma-aware, sex-positive, neurodivergent-affirming practice — and we value referrals that reflect the same care and sovereignty we extend to our own clients.