This Disclosure, Consent and Waiver Form (“Form”) is entered into by the undersigned person (“Participant”) who wishes to participate in telephonic individual coaching sessions conducted by Shelly Young, MA, LPCC, LADAC.  These sessions will provide coaching and information on the practice techniques of mindfulness meditation following the Basic Mindfulness system pioneered by Shinzen Young. The emphasis will be on techniques relevant to emotional and/or physical issues of suffering.

 

Shelly is a Licensed Professional Clinical Counselor in New Mexico, and the laws and regulations of that State will apply.

 

Participant has fully read and understood this Form, and consents to its terms, and any implied risks, with full knowledge of its meaning and contents.  Participant waives the right to attempt in any way to enforce the laws of any jurisdiction other than New Mexico with regard to their participation in individual coaching. Participant confirms that he or she is the person who has applied to participate in telephone coaching with Shelly Young, and that the information given on the application is true and correct to the best of their knowledge.

TELEPHONE DISCLOSURE, CONSENT AND WAIVER FORM

Individual Counseling

  • Wix Facebook page
  • Wix Twitter page
PresentSolutions4U.com
Telephone: (505) 506-3886
Email: Shelly@PresentSolutions4U.com

 

Complimentary 15 minute telephone consultation​

*Most Insurances Accepted for Individual Therapy

 

© 2013 PRESENT SOLLUTIONS, All rights reserved. Use of any content without permission is prohibited.