Withdrawal of Consent Form

To ensure that clients are able to give Informed Consent as they register at NormQuantz.com a copy of  Withdrawal of Consent form  is available here for you to download and/or print to read at your convenience. We want you to fully understand the contract you are entering into and if you have any questions regarding either the content or meaning of any of the forms please ask your questions using the Contact Norm page. We will be happy to fully explain anything that is unclear or concerns you.

You would only use this form if you were wanting to withdraw from Counselling before completeing one of the 4 Phases. You would need to print this form. Complete it and fax to 1-877-221-9808.



I __________________________ the undersigned do withdraw the afore-signed consent for counseling with

I.M.A.G.E. Inc. and counselor _______________________ on the following grounds:_________________



Signed this _____ day of _______________, 20_____

Signed Counselee: _____________________________

Signed Counselor: ______________________________