Parental or Custodial Consent V2


I am the legal guardian for , whose date of birth is:

My relationship to him/her is:  

With regards to the above-mentioned minor, I, the undersigned, understand and give my consent for the following:
I understand that the program of conditioning offered by you will include an undetermined number of private sessions, depending on individual needs.

I understand and agree that the major purpose of this program is for Vocational or Avocational Self-improvement and that those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professions Code 2908). I also understand that there are no guarantees as to the results or progress to be made, only that you will, to the best of your ability, endeavor to accomplish the objective of the sessions.

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Signature Certificate
Document name: Parental or Custodial Consent V2
lock iconUnique Document ID: f29aa4dd97e3be3f8f7f4690ba4d7e0c0fec1d32
Timestamp Audit
January 28, 2025 9:39 am PSTParental or Custodial Consent V2 Uploaded by Kristine Ovsepian - cs.7seo@gmail.com IP 97.107.177.135