I, the undersigned parent or legal guardian, hereby give my consent for my child to receive hypnotherapy services from Jithendran Sellamuthu, C.MH., through VRishi Immersive Hypnotherapy.

I understand that hypnotherapy is a form of vocational and avocational self-improvement and is not a substitute for licensed medical, psychological, psychiatric, or dental treatment.

I understand that I will be asked to meet with the hypnotherapist at least once and witness the signing of this parental release form. If my child is 12 years of age or younger, I understand that the practitioner should meet briefly with me no less than every other session.

I confirm that I have full legal custody of the minor named below. If someone other than a parent has custody, written proof of custody must be provided in addition to signing this form.

I have read the Disclosure of Services and understand the nature of the services being provided.