INSTRUCTIONS FOR USE:

• To schedule phone sessions with Shannon Cutts, please read and sign this Agreement - scheduling will ONLY proceed upon receipt of this signed Agreement.
• Upon receipt of the Agreement, you will be contacted to arrange for your session dates, times, and payment.
• You may return the signed Consent Agreement via fax or mail:
  by Fax: 713-776-0458
  by Mail: c/o Key To Life, 7218 Mobud, Houston, TX 77074

 CONSENT AGREEMENT TERMS:
By signing below, signor(s) or guardian for signor(s), hereby understands and agrees to the following:

• Shannon Cutts is not a licensed counseling professional.
• Shannon Cutts can offer ONLY guidance, mentoring and personal opinion from her own life experiences.
• Shannon Cutts' Key To Life materials/resources and/or ANY email/phone correspondence are not meant to replace any professional medical or psychological advice/support necessary for the management of eating disorders, or any other emotional/mental conditions, and should never be construed as such.
• Signor has voluntarily sought a meeting with Shannon Cutts, and shall never hold her responsible for ANY action taken by himself/herself, or ANY of the parties involved in any of his/her meetings.
• All communication with Shannon is confidential, UNLESS:
        a) it is determined that signor is a danger to him/herself or someone else;
        b) signor discloses abuse, neglect, or exploitation of a child, elderly, or disabled person
        c) by law or institutional authorities, Shannon is instructed to disclose or release information

_________________________ (Printed Name)

_________________________ (Signature)

_________________________ (Parent/Guardian Name - for those under 18)

_________________________ (Parent/Guardian Signature)

_________________________ (Date)