Consent for Private Sessions *
I understand that Educational Kinesiology sessions are educational experiences designed to assist in harmonious integration of physical, emotional and mental aspects within myself or my child and that results vary from person to person. I further understand and agree that no medical diagnosis, prognosis or treatment is expressed or implied in these sessions. I understand that these sessions are not to replace medical advice and/or intervention if that is what is needed. I hereby consent, authorize and request Kelsey Fox Bennett to facilitate these sessions as deemed advisable and necessary in accordance with her best expertise. Except in the case of gross negligence or malpractice, I agree to fully release and hold harmless Kelsey Fox Bennett from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). I understand that this educational work may require touching on the body in the form of muscle re-education, acupressure tapping, physical play for children or other healing activities and techniques. It may also include essential oils to support overall health and wellness. This has been explained to me and I consent and authorize Kelsey Fox Bennett to do this work. I understand that I am responsible for payment prior to or at the time of services rendered. I am also responsible for payment of sessions canceled without 24 hours notice. In addition, I understand that this work requires at-home follow through for best results and am willing to take responsibility for that follow through.
Additional Parent Agreement (If Applicable)
I understand that the success of Kelsey's work involves at-home participation and integration. I agree to facilitate this process by helping my children complete the techniques Kelsey shares on a daily or weekly basis per her recommendation. I also understand that Kelsey requires 1 parent over-the-phone session per every 4 child sessions. My active participation supports my child's success as well as the family dynamic and environment.
My Name *
My Name
My Child's Name (If Applicable)
My Child's Name (If Applicable)
Date *