Parent Consultation Form

Parent Consultation Form

Please fill out and submit prior to your consultation
Parent's/Guardian's Name(s) *

First Name Last Name
Parent's/Guardian's Name(s)

First Name Last Name
Email *
example@example.com
Names and ages of your children *
Your Key Concerns: List here your top 1-3 concerns regarding your situation. *
What have you tried? Tell me a bit about what you have tried to do to change the above concerns. *
What has been the outcome of those efforts? *
Your Key Goals: Please list the most important changes or improvements that you would like to see. What would you like to receive from our session(s)? *
What else would you like to tell me that may be of importance?
INFORMED CONSENT FORM:

I hereby attest and agree to the following:
I understand that Mary Dravis-Parrish dba Enhanced Living LLC is certified in Access Bars®,Access Body Processes®, RESET, and is a certified facilitator and is not a licensed physician and cannot diagnose disease, prescribe drugs or recommend treatments for specific diseases.

I understand that Mary Dravis-Parrish does not claim or imply that with any advice, counsel, suggestions, recommendations or services that she may provide whether in person, by mail, by e-mail or by telephone will cure, treat, prevent or mitigate any disease condition.

I certify that Mary Dravis-Parrish has not suggested that I cease any medical care I may now be undertaking. I further state that the decisions I make regarding my health care or the health care of those under my guardianship are my responsibility and that I will not hold Mary Dravis-Parrish or Enhanced Living LLC accountable for any consequences of my decisions.

I further understand that I am responsible to pay for my scheduled appointment in full on the date such service is rendered. If I miss an appointment without giving 24 hour notification, I understand I will be billed $35 per missed hour of appointment– except for approved emergencies.
Signature *

Clear
Date *

Month Day Year
Date
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