Client Information & Consent Form


Thank you for your interest in our Personal Growth Mentoring Program. In order to be able to serve you, we would like some information about you. Please read and submit our consent form which informs you about the program. This information is sent directly to us and is not retained on this website, we do our best to ensure your information stays private.

Client Consent Form

This is an agreement between the client and Jacqueline from Evolve Within in regards to participating in the Personal Growth Mentor Program. By sending this agreement you, the client, agrees to all terms listed in this agreement.

  • I am at least 18 years old, the age of consent to make any decisions towards my healing and wellbeing journey. 
  • I authorize and request Jacqueline to carry out my mentoring sessions. I understand the process of these sessions will be explained to me upon my request and that they are subject to my agreement. I also understand that while the course of my session is designed to be helpful, Jacqueline can make no guarantees about the outcome of my session. During these sessions uncomfortable feelings and reactions such as anxiety, sadness, anger and any other emotions may surface. I understand that this is a normal response to working through unresolved life traumas/experiences and that these reactions will be worked on between Jacqueline and I, the client. 
  • Any communication via email, social media, or cell phone texting may not be secure, and you have agreed that using these communication channels to provide information are taking the risk of such communication being intercepted.
  • By supplying us with specific phone numbers and contact information, you authorize us to be able to leave you business related messages.
  • All information between Evolve Within and you, the client, is held strictly confidential. There are legal exceptions to this:
  1. The client authorizes a release of information with written consent.
  2. The client presents as a physical danger to self or others.
  3. Abuse and/or neglect are suspected.
  4. The client is under criminal investigation and a subpoena by a court of law has been issued for information on the client.

In the case of #2 & #3 above, we are required by law to inform potential victims to legal authorities so that protective measures can be taken.

  • I understand that I am responsible for payment of the program before starting and there are no refunds on services.
  • Jacqueline reserves the right to respond to my messages when time is available for her and does not need to provide explanations towards her availability.
  • I understand that my relationship with Jacqueline is entirely professional and any behavior on my part that is not professional and can be deemed sexual or abusive will be reported to the authorities and sessions will be canceled immediately, without any refund.

In message box reply with "I consent".

With sending my information, I consent and certify that I have read and understand this agreement and have full knowledge of its meaning and effect. If I violate the agreement, I accept that Jacqueline may cancel any current and future sessions.

**Feel free to use the Message box to add any info you feel is needed to keep on file.**