Parental/Guardian Consent Form

AGREEMENTThank you for providing your consent for your child to participate in services with Mindful InnerChange and/or Energetic Awakening. All children under the age of 18 are required to have written parental / guardian consent.

Minor Client's Name *I / We, parent(s) or guardian(s) do hereby give permission for the above-named minor to participate in sessions including, but not limited to, Hypnotherapy, Emotional Freedom Techniques (EFT), Meditation, QiGong, Yoga, and Energy Healing. I / We understand that hypnosis, somatic treatments (EFT, Yoga, Qigong) means to engage in treatments meant for self-improvement. I / We also understand that the other complementary service by Mindful InnerChange and Energetic Awakening serves the same purposes. I / We have been advised by Mecca Wagner-Brown and/or Shayna Boyer of the scope of services, and I / We give full consent for the above-named minor. I / We understand that results vary and that the above-named practitioners may not guarantee results. Marketed services not a replacement for medical treatment, psychological or psychiatric services, or counseling. I / We also understand that the practitioners stated above, do not treat, prescribe for, or diagnose any condition. I / We understand that the practitioners are facilitators of marketed services and are not practicing any other profession that requires a license under the laws of the State of Arizona. I / We understand that Mecca Wagner-Brown and Shana Boyer will maintain the confidentiality of information obtained about and with the child and will only release information if I do hereby give my consent. (Your signature also acknowledges you have all legal rights to make decisions regarding this minor and services requested. You also acknowledge you have read and completed the client confidential intake consent form.) We absolve all parties concerned with this treatment from any and all claims.

PARENT/GUARDIAN #1 INFORMATION

First Name *

Last Name *

Relationship to Minor: *

Email Address: *

Phone: *

Street Address: *

Apartment, suite, etc:

City: *

State/Province: *

ZIP / Postal Code: *

Country: *

PARENT/GUARDIAN #2 INFORMATION

First Name

Last Name

Relationship to Minor:

Email Address:

Phone:

Street Address:

Apartment, suite, etc:

City:

State/Province:

ZIP / Postal Code:

Country: