Mentorship Consent Form Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Date of Birth - Please include day and year, time of day if known and city/town and country I understand and agree to participate in mentorship sessions with Stephanie, during which she may utilize techniques such as IFS (parts work) therapy and Medical Qigong therapy, as well as draw upon her experience as a counsellor. I understand that these sessions are for the purpose of providing guidance and support, and are not a replacement for clinical counseling or therapy. I acknowledge that the fee for each mentorship session is $220 US per hour and is non-refundable after the session commences. If I cancel the session within 24 hours of the scheduled time, a 50% fee will be deducted from my payment. If I cancel after 12 hours of the scheduled time, the full fee will be charged. I understand that the information shared during the mentorship sessions will be kept confidential, except in cases where Stephanie believes there is a risk of harm to myself or others. I understand that this is not a clinical counseling session. I also understand that I have the right to terminate the mentorship sessions at any time. I consent to providing my address and emergency contact information to Stephanie ahead of sessions in case of any emergency. I have read, understood, and agree to the terms outlined in this consent form for mentorship. Signature * Date * By typing my name above, I agree that this is my digital signature, and I agree to the above terms. Please note that this intake form is confidential and will be kept securely on file. Thank you for taking the time to provide this important information. Thank you!
