This agreement (“Agreement”) is entered into by and between [Name of patient] and Dana Shalit (collectively, the “Parties”).

Governing Law

The Parties hereby agree that:

a)  all aspects of the relationship between [Name of patient] and Dana Shalit (as well as his/her agents, delegates, employees, and any physicians and other independent healthcare practitioners providing medical or other healthcare and treatment to [Name of patient], or in association with Dana Shalit, including without limitation any medical or other healthcare and treatment provided to [Name of patient], and

b)  the resolution of any and all disputes arising from or in connection with that relationship, including any disputes arising under or in connection with this Agreement, shall be governed by and construed in accordance with the laws of the province or territory of Ontario (other than conflict of laws rules) and the laws of Canada applicable therein.

Exclusive Jurisdiction

The Parties hereby acknowledge that the medical or other healthcare and treatment received by [Name of patient] from Dana Shalit will be provided in the province or territory of Ontario, and that the Courts of Ontario shall have exclusive jurisdiction to hear any complaint, demand, claim, proceeding or cause of action, whatsoever arising from or in connection with that medical or other healthcare and treatment, or from any other aspect of the relationship between [Name of patient] and Dana Shalit.

 

I, (The Client), hereby release Dana Shalit from any liability or claims that could be made against (him/her) concerning my mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form.

 

Scope of Practice

I understand that Dana Shalit is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnosis should not be considered a replacement for the advice and/or services, of a psychiatrist, psychologist, psychotherapist, or doctor.

Participation

I give Dana Shalit full permission to hypnotize me and to use Rapid Transformational Therapy knowing that by participating fully in the process and by listening to my personalized recording for 21 days I play an important role in my overall success.

Guarantee

I understand that although Rapid Transformational Therapy has an incredibly high success rate, Dana Shalit cannot and does not guarantee results since my own personal success depends on many factors that Dana Shalit has no control over, including my willingness and desire to affect the changes inside of myself.

Audio Recording(s)

I give Dana Shalit full permission to make audio recordings that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s) Dana Shalit retains full copyright over any forms of media that may be produced and distributed to me.

Deepening Process

I hereby grant permission to Dana Shalit to respectfully lift my arm, touch my shoulder, or rock my head during my Rapid Transformational session(s) in order to help facilitate the deepening process.

Confidentiality

By signing this form, I consent that Dana Shalit may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.

I also understand that, at any time, Dana Shalit may discuss aspects of my case with other colleagues keeping my full name. Identity completely confidential always unless I have given permission otherwise.