Parent/Guardian Name Legal Name *

First Name

Last Name

Child Legal Name *

First Name

Last Name

Parent/Guardian Mailing Address *

Address 1

Address 2

City

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Parent/Guardian Cell Phone *

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Child's Physician/Therapist Name

(if applicable)

First Name

Last Name

I give permission for Shelly Baca and Rising Earth Academy, LLC to work with my child. I understand that good and lasting results may require several sessions and that my child may be required to practice self-hypnosis and/or listen to a reinforcement recording between sessions/at home. My child is responsible for actively cooperating with and participating in this program. Shelly Baca and Rising Earth Academy, LLC shall not be held accountable for the results my child attains. I understand that this program may be terminated if deemed appropriate and that my child may be referred elsewhere for proper treatment. I have read the Client Bill of Rights and I understand that all information about my child will be kept strictly confidential. *

I agree

I do not agree

I have reviewed the Client Bill of Rights linked at the top of this page. I understand that by checking "I agree" below I am submitting an electronic signature confirming I have thoroughly examined and understand the Client Bill of Rights.

I agree

I do not agree

Child's Physician/Therapist Phone Number

(if applicable)

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