Minor Consent Form

Required for all clients under the age of 18

This form must be completed by a parent or legal guardian before the minor's first session. Arizona law requires written parental or guardian consent for minors receiving care or treatment. (A.R.S. §13-3620)

Thank you for trusting your child's wellbeing to this work. Please read through carefully — there are a few important things about confidentiality and reporting that I want to make sure are clear before we begin.

Minor's information

Minor's full name

Date of birth

Age

Type of session

Parent / guardian information

Full name

Relationship to minor

Phone number

Email address

Emergency contact (if different from above)

Name & relationship

Phone number

Confidentiality & reporting

Session content is held in confidence. I will not share the details of what your child shares with me with you as their parent or guardian, except in the following situations:

Risk of harm: If I have reasonable belief that your child is at risk of harm to themselves or others, I will communicate that with you and, if necessary, contact emergency services.

Suspected abuse or neglect: Under Arizona law, I am required to report reasonable suspicion of abuse, neglect, or non-accidental injury involving a minor to the appropriate authorities — including suspected in-home abuse. I am a mandated reporter under this statute. (A.R.S. §13-3620)

Outside of these situations, what your child shares in sessions is theirs. This boundary is intentional — it helps build the safety that makes the work possible.

Parent or guardian presence: A parent or guardian is welcome to remain present during any session. Please let me know your preference before we begin.

Your agreement

Please check each item:

I understand that BCST and Health Coaching are not medical treatment and do not replace the care of a licensed medical or mental health provider. I give informed consent for Jennifer Weech of Nested Hearth LLC to provide sessions to the minor named above, and understand that sessions may be stopped at any time. I understand that session content is confidential, and that Jenn will not share what my child discloses except in situations involving risk of harm or mandatory reporting obligations under A.R.S. §13-3620. I understand and agree to the cancellation policy: 48 hours or more — no charge; 24 to 48 hours — half fee; less than 24 hours — full session fee. I confirm that I am the legal parent or guardian of the minor named above and have the authority to consent to these services.

Signature of parent / guardian

Print name

Date

Signature — write or type your full name.

When you send this, the completed consent travels straight to me by email — nothing is stored on this page or shared anywhere else.

Email app didn't open?

Copy your responses below and paste them into an email to jenn@nestedhearth.com.

Signed and sent.

Your email should have opened with the completed consent ready to send — just press send and it comes straight to me. If it didn't open, you can reopen the form and copy your responses instead.

Thank you for trusting me with your child's care.