Minor Permission Form

Minor Intake and Permission Form
1. Non-Medical Services: The alternative emotional healing services provided by Healing the Heart ATX (Heidi Wells) to minors are not intended to replace or substitute for professional medical or psychological treatment. The services offered are not intended to diagnose, treat, cure, or prevent any medical or mental health conditions. It is recommended that you consult with a qualified medical or mental health professional for any medical concerns regarding your child.
2. Voluntary Participation: Your child's participation in any sessions or use of any services provided by Healing the Heart ATX (Heidi Wells) is voluntary and at your own risk. You understand that the services are complementary and alternative in nature, and the outcomes cannot be guaranteed. You have the right to refuse or discontinue any sessions or services for your child at any time.
3. Parental Responsibility: As a parent or legal guardian, you acknowledge and understand that you are solely responsible for the well-being of your child before, during, and after any sessions or use of any services provided by Healing the Heart ATX (Heidi Wells). You agree to take full responsibility for any decisions, actions, or consequences arising from your child's participation.
4. Confidentiality: Healing the Heart ATX (Heidi Wells) respects the privacy of minors and will maintain confidentiality to the extent permitted by law. However, please be aware that there are limits to confidentiality, and in certain circumstances, the practitioner may be legally obligated to disclose information, such as suspected child abuse, harm to self or others, or as required by a court order.
5. Refunds: To maintain the integrity of the healing process and promote personal responsibility, no refunds will be issued for any sessions or services provided by Healing the Heart ATX (Heidi Wells). We believe in your child's ability to apply the healing tools and techniques provided for their own growth and well-being.
6. Cancellation Policy: A 24-hour cancellation notice is required for any scheduled sessions involving your child. Failure to provide the required notice will result in being charged the full session rate.
By permitting your child to participate in any sessions or utilize the services provided by Healing the Heart ATX (Heidi Wells), you, as the parent or legal guardian, acknowledge that you have read, understood, and agreed to the terms and conditions set forth in this legal disclaimer.
I, (Parent/guardian's full name), and(Parent/guardian's full name) give my permission for my child,(Child's full name), to participate in sessions and receive alternative emotional healing services provided by Healing the Heart ATX (Heidi Dwyer).
Parent's Name (1)

First NameLast Name
Parent's Name (2)

First NameLast Name
Child's Name

First NameLast Name
Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Areas of concern/significant past traumas:
Session goals:
Signature Parent 1

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Signature Parent 2

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Should be Empty:

Minor Intake and Permission Form