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.