Consent formPlease enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Cell Phone Number *Email *Dctor's name and phone number *Consent for Psychotherapy. Please check the following boxes to consent: *I consent to receive counselling/psychotherapy from the Parents’ Coach Network and I have the right to withdraw my consent at any time.I acknowledge that I will give 48-hour notice to cancel my appointment or a full session fee will be charged.I acknowledge that all health information collected is private and confidential. I give permission to receive and disclose my health information within the team of the Parents’ Coach Network and other health care professionals if necessary for consultation purposes.I acknowledge that the Parents’ Coach Network is not an emergency service. I will call 911, go to the nearest hospital, or call 988 mental health crisis line in case of an emergency.I acknowledge that the Parents' Coach Network does not offer direct billing, and payment is kindly required before each session to confirm your appointment.Consent for the NADA Protocol Auricular AcupunctureI have read and understood the information given regarding the NADA Auricular Acupuncture.I understand that auricular acupuncture is a complementary therapy and is not a substitute for medical or psychological diagnosis or treatment.I agree that the clinic and practitioner are not liable for any adverse effects or outcomes resulting from my participation. Your participation is voluntary. You may refuse treatment or withdraw your consent at any time without penalty or loss of services.I release the practitioner and associated facility from any liability that may arise in connection with my participation in auricular acupuncture sessions.I consent to receive auricular acupuncture treatment using the NADA protocol. The practitioner providing this service is trained and certified in the NADA protocol.Signature *Submit
