Expat Adjustment Counseling Liability Release Form
Please complete all fields below to acknowledge and release liability for expat adjustment counseling services. Read the acknowledgment carefully before signing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Country of Residence
*
Please Select
United States
United Kingdom
Canada
Australia
Germany
France
Singapore
United Arab Emirates
Other
Home Country
*
Please Select
United States
United Kingdom
Canada
Australia
Germany
France
Singapore
United Arab Emirates
Other
Counseling Service Type
*
Please Select
Individual Counseling
Couples Counseling
Family Counseling
Group Counseling
Adjustment Support
Other
Counselor or Provider Name
*
Session Date(s) or Date Range
*
Liability Release Acknowledgment
By signing below, I acknowledge that I have voluntarily chosen to participate in expat adjustment counseling services. I understand that these services are not a substitute for medical, psychiatric, or psychological treatment. I agree to release and hold harmless my counselor/provider and their organization from any and all liability arising from my participation. I have read and understand this acknowledgment.
Signature
*
Submit
Submit
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