Minor Clients

Consent to Work with a Minor

* Indicates required field

Name of Minor Client *

First

Last

Client Email *

Name of Parent of Legal Guardian *

First

Last

Parent/Guardian Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

I understand that by signing this agreement I give permission for hypnotherapy and/or behavioral therapy to be performed by a Certified Clinical Hypnotherapist at AMARA Hypnotherapy. I also understand that hypnotherapy is not a medical or psychiatric practice, but rather is an aid in helping to overcome obstacles and enhance personal growth. Hypnotherapy is a form of relaxed concentration which has been approved by the American Medical Association for over 800 uses. In addition to hypnotherapy, the client will be encouraged to make use of suggested positive behavior changes for maximum success. It is understood that any of the services used in this office are not to be used in place of medical treatment. *

Yes, I give my consent for treatment

Parent/Guardian Electronic Signature *

First

Last

Date --/--/---- *

Submit

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Consent to Work with a Minor