Consultation Agreement

 

 

 

Consultation Date:   ______/_____/______

 

 

Legal Name:  ___________________________________________________

 

 

Address:  ______________________________________________________

 

City:  _________________________________________________________

 

State:  _________________________________________________________

 

Zip:  __________________________________________________________

 

 

Phone:  ________________________________________________________

 

Email:  ________________________________________________________

 

 

In signing this, I understand that I and only I, am responsible for any and all information.  I also do not hold my consultant responsible for anything concerning this consultation.  I further agree that all modalities consultations offered are not a replacement or substitute for medical or psychological treatments.

 

Signature:  _____________________________________________________

 

Date:  _____/_____/_______