Group Session: Pure Natural

Group participation intake form

Sharlene Styles, PURE Natural Health & Wellness clients. Presented by: Diane Konkin, Advanced Mind Health
Name

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Date of birth

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Health conditions and medications
Are there any challenges or factors in your life that may affect reaching your goals?
If you could remove or change one eating habit, what would that be?
What are the reasons you eat other than hunger?

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TERMS AND CONDITIONS

Please Read. You will be asked to agree below.

Personal and Medical information
The information I have provided is thorough and correct.
By choosing to partake in the group RTT® session, I confirm that I do not have epilepsy, psychosis or any current mental health or medical issues that would be agitated while being in a relaxed state or state of hypnosis.

Scope of Practice
I understand that Diane Konkin is not a licensed physician, psychologist, or medical practitioner, and that Rapid Transformational Therapy® should not be considered a replacement for the advice and/ or services, of a medical professional.

Liability
I understand that the RTT® method focuses on understanding and reframing root causes of my issues which may be an emotional experience, and hereby release Diane Konkin and Advanced Mind Health from any liability or claims that could be made against her/them concerning my mental and/or physical well-being during the work that has been agreed upon, now and in the future.
For residents outside of Canada: I acknowledge that the resolution of any and all disputes arising from or in connection with this business agreement, relationship and exchange, shall be governed by and construed in accordance with the laws of Ontario, Canada.

Participation
I fully understand that Rapid Transformational Therapy® involves using relaxation, hypnosis, and guided visualization and agree to participate in this session. I understand that at any time I can step away from the group if I wish to. I acknowledge Diane Konkin is a certified RTT® therapist and hypnotherapist.
I understand and agree that my overall success is dependent on fully participating in the process including listening to the provided audio recording daily for a minimum of 30 days.

Guarantee
I understand that although Rapid Transformational Therapy® has a typically high success rate, individual results cannot be guaranteed. I recognize success depends on personal factors including a willingness and desire to affect personal change.

Audio Recording
I understand Diane Konkin retains full copyright over any audio recordings that are produced and distributed to me. I agree NOT to duplicate or share my personal recording.

Confidentiality & Privacy
I understand that my personal information will not be sold to any third party or my email used for unsolicited mail. Any emails sent by this Company will only be in connection with the provision of agreed services.

Punctuality
I acknowledge that I will only be given approximately a 15 minute grace period for lateness for this group session and that if I am not present for the beginning of the session, I may not be admitted into the meeting and forego my participation unless a session becomes available at a later date.
I have read and agree to the Terms and Conditions

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Group participation intake form