Gomaa Life Coaching & Consulting LLC
Parent / Legal Guardian Consent Form
For clients under 18 years old
Minor & Guardian Information
Minor Client Name *
Date of Birth / Age
Parent / Legal Guardian Name *
Relationship to Minor
Phone
Email *
Emergency Contact Name
Emergency Contact Phone
Session Type
Session Mode
Select…
In Person
Online
Phone
In Person & Online
Terms & Conditions
1. Consent and Authority:
I am the parent or legal guardian of the minor named above, and I give permission for the minor to participate in coaching services with Gomaa Life Coaching & Consulting LLC. I confirm that I have legal authority to provide this consent. If any custody order, parenting plan, court order, or legal restriction affects my authority, I agree to disclose it before services begin.
2. Scope of Services:
I understand that these services are educational and coaching-based only. They may include life coaching, personal development, communication skills, goal-setting, decision-making, confidence-building, social skills, and practical life-planning support.
3. Not Therapy or Counseling:
I understand that these services are not therapy, psychotherapy, psychological counseling, mental health counseling, medical treatment, legal advice, crisis intervention, or diagnosis or treatment of any mental health, medical, emotional, behavioral, or psychological condition.
4. Parent Responsibility:
I understand that coaching does not replace parental supervision, medical care, therapy, counseling, school support, legal advice, or any other professional service that may be needed. I remain responsible for the minor's health, safety, supervision, and overall well-being.
5. Privacy and Safety Limits:
Reasonable efforts will be made to respect the minor's privacy. However, information may be shared with a parent/legal guardian, appropriate authorities, emergency services, or other necessary parties when required or permitted by law, or when safety concerns exist, including suspected abuse, neglect, exploitation, risk of harm, threats of violence, crisis, court order, subpoena, or legal requirement.
6. Emergencies:
Gomaa Life Coaching & Consulting LLC does not provide emergency services, crisis response, suicide prevention services, or 24-hour support. If the minor is in immediate danger or needs urgent medical or mental health help, I will contact 911, the nearest emergency room, or an appropriate licensed professional immediately.
7. Online Sessions and Recording:
I give permission for the minor to participate in coaching sessions in person or online by video, phone, or another agreed method. I agree to help ensure a safe and appropriate setting.
No session may be recorded by any person without prior written permission.
8. Information and Withdrawal:
I will complete all forms and provide any required information. I may withdraw this consent at any time by written notice. Withdrawal does not remove any payment, cancellation, or other obligations already incurred, unless agreed in writing.
I have read, understood, and agree to this Parent/Legal Guardian Consent Form.
Signature
Parent/Legal Guardian Printed Name *
Minor Client Name
Parent/Legal Guardian Email *
Date *
Parent/Legal Guardian Signature *
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