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All About You Wellness Centre

Parental Consent & Client Information Sheet

Date *

Child's Name *

First

Last

Parent's Name *

First

Last

Child's Birthday *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent's Contact Number *

Child's Contact Number *

Child's Email (if applicable)

Child's Gender *

Male
Female
Non – Binary
Prefer not to say

Please describe in your own words your objective for your child for the sessions. How would you expect your child’s life to change once you meet your objective? *

Terms and Conditions

Cancellations must be made at least 24 hours prior to the scheduled appointment. If cancellations are made less than 24 hours the full session fee will be charged. Should the client fail to show up, the full session fee will be charged.
All prior payments are non-refundable and non-transferable, except in special circumstances and All About You (‘AAY’) reserves the right to the final decision.
The Parent agrees on behalf of the client that all practices done on, for, or even by them at AAY are done with their full consent and at their will.
The Parent on behalf of the client attests that the client has no mental or psychological ailment/disorder and are not on any psychiatric or psychological treatments and/or drugs.
The Parent on behalf of the client agrees to indemnify, release, remise and forever discharge, the treating practitioner, AAY, its employees, its consultants, its property owners or anyone at AAY from any obligation or liability whatsoever, all claims, demands, damages, injuries, actions or causes of actions whatsoever, before, during or after volunteering to participate in such sessions.
The Parent on behalf of the client is aware of the modalities of therapy used and understands that the result may also depend on external factors and the client’s own efforts.
The parent on behalf of the client is aware that the session is private and only involves the client and therapist, and thus the client shall not bring parents, friends or relatives to the session room unless they are related to the case and previously discussed with the therapist. The client understands that pets are not allowed at All About You centre and shall not bring any pets/ animals to the centre under any circumstances.

Privacy
By signing this form, you understand and agree: Your personal data (name, contact details, interests,) may be used by AAY to contact you and inform you about our latest news, events, promotions, offers, workshops, seminars and other exciting happenings at AAY. Please note that you may change your mind at any time and ‘opt-out’ of our mailing list by either writing to us at info@soniasamtani.com or by clicking ‘Unsubscribe’ in any of our email communications.

Confidentiality
All information discussed in the sessions will be treated as confidential information and will not be disclosed to any third party unless prior permission is granted or unless disclosure is required by law. However, counselors are ethically and/or legally required to disclose confidential information to the appropriate authorities in four kinds of circumstances:

● If a client indicates that they or another person may be a danger to themselves or others
● In the case of apparent, suspected or potential child abuse or neglect
● If clients report sexual abuse by a regulated health professional
● When a court issues a summons for records of testimony

From time to time your practitioner may consult another for supervision, in order to improve the quality of services provided, without using personally identifiable information. Other than the four circumstances listed above, your practitioner cannot converse, write or give any information about you or your circumstance, without your verbal or written informed consent to do so.

I have read and accepted the above terms and conditions above and give consent for my child to take sessions with All About You.

(This agreement is valid from the date signed until further notice.)

Parent's Name *

First

Last

Please type your name to confirm all the information above. This will serve as your e-Signature. *

Date Signed *

I do not wish to receive any direct marketing information about AAY’s latest news, events, promotions, offers, workshops, seminars and other related news that AAY may send from time to time.