CLIENT INFORMATION FORM

1. NMT provides non-legal, non-medical, and non-clinical advocacy, information, and support services only. Nothing communicated by NMT staff or volunteers is intended to constitute, and shall not be construed as, legal advice, medical advice, psychiatric or psychological treatment, diagnosis, or therapy. No attorney–client or doctor–patient relationship is created by obtaining assistance from NMT.

2. NMT cannot control the actions of other people and cannot promise any particular outcome, including but not limited to the issuance of injunctions, decisions or actions by law enforcement or the State Attorney, availability of shelter, employment, or the future conduct of any other person. To the maximum extent permitted by Florida law, NMT shall not be liable for any indirect, special, incidental, consequential, or punitive damages arising out of or related to the use of NMT’s services.

3. I acknowledge that I have the right to expect my communications with NMT to be treated as confidential. I have the right to refuse to speak with or meet anyone not affiliated with NMT. I am entitled to be interviewed in a private setting where my privacy is respected, and to have discussions about my case conducted discreetly with only those directly involved present, unless I give permission otherwise. NMT may share information with outside individuals or agencies on a strict need-to-know basis in order to provide the support I am requesting. I understand that I may revoke this permission in writing at any time, except to the extent NMT has already relied on it.

4. I understand that NMT is not 911 or a law enforcement agency and may not be able to answer or respond immediately to calls, texts, emails, or other communications. In any situation that I believe is an emergency or involves an immediate threat to life or serious bodily harm, I agree to contact 911 or an appropriate domestic violence hotline.

5. If NMT reasonably believes that I or another identifiable person faces an imminent risk of serious harm, NMT may, in its discretion and consistent with applicable law, contact emergency services, law enforcement, child protective services, or other appropriate authorities.

6. I confirm that the information I have provided to NMT is, to the best of my knowledge and belief, accurate and complete. I understand that NMT will rely on this information, and that withholding or misrepresenting information may affect the appropriateness or effectiveness of the support services provided by NMT.

7. NMT has explained its services, confidentiality practices, and my options for seeking other assistance, and I have had an opportunity to ask questions. I affirm that I have read (or had read to me) this agreement, understand it, and voluntarily agree to receive the services I am requesting from NMT. I understand and agree that NMT will provide assistance for up to four (4) days.