Adult Permission Requirement
Parental permission is required for sessions for any person under
18 years of age.
You must be the parent/legal guardian.

If you want to give permission for online sessions,
and if you are the parent/legal guardian,
fill out the form below
giving your name and information.
Type "yes"
if you are the parent or legal guardian.
Type "yes" in the box if you
understand that the information
provided above will not be shared
except as required by law.
Type "yes" in the box if you
understand that their are legal limits to
confidentiality and that I am required
by law to report to the authorities any
awareness I have of sexual abuse,
neglect of a minor or of the elderly, of
crimes, and of any danger you pose to
yourself or others.
By typing "yes" in the adjacent box, I
certify that I am the
parent/legal guardian of this minor.
Name of Minor
If we were doing this work commercially,
we would ask for a donation of $60.00 per session.

However, because this is a Christian ministry,
we want to make it available at a cost that fits your budget.

If you decide to continue with sessions
after the initial free consultation,
please choose a rate for each session.

Around the first of each month,
we will send you a statement to your above address
itemizing the time I have spent on your concerns.

We ask payments be sent to our post office box rather than our street address.

Send a check or money order to
Becoming
PO. Box 364
Crockett, TX 75835

Remember, the first consultation is free.
Deciding on a rate is for future sessions, if you choose to continue.

A limited number of scholarships are available
due to some caring people who help underwrite the cost of the ministry.
Choose Rate per session
for future sessions
after the free consultation
To further confirm parental and legal guardian permission
to work online with a minor,
we will mail you a form at the above address
so we can have your signature of file.

Thank you for allowing us to serve you.

Don
Some firewalls interfere
and you receive a "page not available"
message after submitting the above form,
even though the information has been sent.

If this happens, please email me at
donmize@yahoo.com.

I will check to be sure your information came
through and confirm by return email
April 26, 2006