Parental or Custodial ConsentTo be used with any client under the age of 18 years Today's Date * MM DD YYYY Minor's Name * First Name Last Name Minor's Birthdate * MM DD YYYY Relationship to Minor * 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 hypnotherapy with Carol Benton, C.Ht. of Optimize Life, LLC 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. * Driver's License Number of Legal Guardian Please check the box below * By checking this box, I affirm that I am the parent or legal guardian of the minor whose details are reported above. I have read and agree to the terms above. Thank you!
