WP E-Signature by Approve Me - Sign Documents Using WordPress -

Parental or Custodial Consent

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.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

July 31, 2024 10:53 am PDT

Parental or Custodial Consent Uploaded by Kristine Ovsepian - kristine@journeystoheal.com IP 97.107.177.135