Parent Consent and Agreement Form

This Performance Coaching Parent Consent Form is between Itzik Rapaport and the Parent/Legal Guardian of the Client to give consent for Mental Coaching with your son/daughter/ward.

First Name

Last Name

Age

Mother's Name and Phone Number

Father's Name and Phone Number

Date of Session Commencement

I give consent to my son/daughter taking part in the coaching activities and assignments conducted by Certified Mental Performance Coach Itzik Rapaport.

I understand and accept that results or outcomes are not guaranteed and that my child is responsible for the results of mental performance coaching.

I give consent for my son/daughter to be contacted by Itzik Rapaport either by phone or text on the contact details listed above for the purpose of mental performance coaching.

I understand that my son/daughter’s participation in mental performance coaching is voluntary and can be withdrawn at any stage in writing.

I understand any personal information collected during my son/ daughter’s participation in mental performance coaching is strictly confidential unless Itzik Rapaport determines that it is his duty of to inform me or another professional or relevant governing body of risk of harm to themselves or others.

I understand and accept that mental performance coaching is not a substitute for counseling, psycho- therapy and/or any mental health service, but rather an alternate method.

I understand if I have any questions or concerns relating to my son/ daughter’s participation in mental performance coaching, I can contact Itzik Rapaport on his cell phone number at 818-942-4466 or email him at itzik@mentalcoachpro.com.

Payments and Cancelations

Parent must leave a credit card on file. Parent can pay cash, charge or Venmo prior to each session. In the event of cancelation or reschedule Parent must notify 24 hours in advance, otherwise they agree to be charged for the session.

Credit Card Charges will appear as "Mental Coach Pro"

Ticking the boxes above indicate consent and a full understanding of the Coaching Parent Consent Form with the information outlined above.

Parent Consent and Agreement Form

Payments and Cancelations

Submitted Successfully!