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Consent Form for a Minor
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Last Name, First Name of CLIENT *
CLIENT Birthdate *
MM
/
DD
/
YYYY
CLIENT Telephone *
CLIENT Email Address *
List any medications you are currently taking (CLIENT) *
As the CLIENT, are you under the care of a psychotherapist? *
If yes, please provide their name and phone number
Last Name, First Name of PARENT/LEGAL GUARDIAN *
PARENT/LEGAL GUARDIAN Telephone *
PARENT/LEGAL GUARDIAN Email Address *
Address, City, State, Zip *
How did you find me? *
I give full consent and acknowledge that I understand the nature of the body-mind process and realize it is not psychotherapy or a substitute for psychotherapy. I take full responsibility for consultation with a medical doctor or therapist regarding any concerns about my child's participation. I agree to hold Emperador Enterprises/Sol Discovery/Jennifer Emperador not liable for any complications resulting from this work. I agree that my child can participate with Emperador Enterprises/Sol Discovery/Jennifer Emperador in the process of their healing journey with my acknowledgement and approval and that I am 18 years or older.  PARENTAL/LEGAL GUARDIAN FIRST and LAST NAME + TODAY'S DATE below. *
LATE/NO SHOW/CANCELATION POLICY: Unless given prior notification, there is a 10 minute grace period in which a client can be considered tardy for their appointment. If more than 10 minutes late, she/he may be rescheduled based upon the practitioner’s availability or seen during their scheduled session time in which the session will end at the original allotted time. She/he will be charged full payment for their scheduled session even if tardy . No shows or cancellations that are not given at least 24 hour notice are also subject to full payment.Scheduled appointments: Full payment must be made at least 24 hours prior to scheduled appointment. Otherwise, they are subject to cancellation. Thank you! *
REFUND POLICY: To honor your needs, I put a lot of preparation into your session. There are no refunds available on sessions canceled within 24 hours. However, you may reschedule your session if canceled within 24 hours. Unused sessions may be gifted to a friend or family member. *
Disclaimer: Emperador Enterprises/Sol Discovery does not provide medical diagnosis or consultations related to health, medical or psychiatric issues; nor does it serve as substitute for medical or psychological diagnosis and treatment. It is recommended you see a licensed physician or licensed healthcare professional for any physical or psychological ailments you may have.  By utilizing the services and information provided by Emperador Enterprises/Sol Discovery, you acknowledge and agree to fully release, indemnify, and hold harmless, Emperador Enterprises/Sol Discovery and others associated with Emperador Enterprises/Sol Discovery, from any claim or liability whatsoever, including without limitation, direct or indirect, special incidental, compensatory, exemplary or consequential damages, losses or expenses. Any information, stories, examples or testimonials presented on the Sol Discovery website does not constitute a warranty, guarantee, or predication regarding the outcome of a treatment with Emperador Enterprises/Sol Discovery. You may not disseminate, modify, copy, in whole or in part, such copyrighted material unless specifically or permitted to do so by Jennifer Emperador (Emperador Enterprises/Sol Discovery). By continuing to explore this website, or choosing to respond with and receive any coaching, breath work or energy sessions from Emperador Enterprises/Sol Discover, you agree to all of the above. *
                                        602.502.0307 | Tempe, Arizona | www.soldiscovery.com
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