UTIU- Disclaimer Form v2
  • UNLEASH THE INNER U REALIZATION TO TRANSFORMATION

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  • Thank you for expressing an interest in working with Unleash the Inner U professional services. The following are standard Terms and Conditions applied

    for the nature of the services offered.

    Signatures are required at the end, as a standard statutory process prior to beginning any sessions. Please review, sign (where indicated) and send back to the therapist via Email or What's App/iMessage or Hand delivery or electronic delivery. Thank you. We look forward to your participation in the Therapy consultations/Coaching and/or RTT (Rapid Transformational Therapy) sessions to help you, unleash all that you are truly meant to be in your life. To truly

  • DISCLAIMER FORM

  • I, The Client (now referred to as I or Me/My or The Client) hereby release Unleash the Inner U, Rachna K, from any liability or claims that could be made against (him/her and/or the company) concerning my mental and/or physical well-being duringthe work that has been outlined and agreed upon (now and in the future) by signing this form. This form is a binding legal contract between the Client and Unleash the Inner U ( now referred to as UTIU UTIU is a d/b/a (doing business as) of Creating a Better World LLC), a New York, USA limited liability company.

    The Client understands that UTIU is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnotherapy should not be

  • UNLEASH THE INNER U REALIZATION TO TRANSFORMATION

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  • considered a replacement for the advice and/or services of a psychiatrist, psychologist, psychotherapist, or doctor.

    UTIU may ask questions about the Client's medical history to establish any contra-indications to treatment. This will also help to assess whether the Client's health is affecting (or being affected by) the therapeutic goals the Client wishes to achieve. Please update UTIU of any medical changes during the Client's course of therapy, or if the Client is returning to therapy after a period of

    If the Client is receiving care or treatment from any medical, healthcare or therapy practitioner, e.g. GP, Psychologist, Psychiatrist or Counsellor, the Client is responsible to seek their permission before any therapy sessions can commence. The Client is responsible for obtaining permission from their existing relevant medical, healthcare or therapy practitioner prior to engaging in any session with

    Please note, UTIU will be unable to offer any professional services if the Client suffers from epilepsy or any form of psychosis.

    I give UTIU, full permission to hypnotize and regress 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.

    The Client agrees not to attend sessions under the influence of alcohol or recreational drugs, except those medications which have been prescribed by the Client's doctor. If the Client does attend any session under the influence of alcohol or recreational drugs, or demonstrate violent or abusive behavior, the therapist will cancel the session and may refuse to see the Client for any further sessions without refunding any payment already made.

  • UNLEASH THE INNER U REALIZATION TO TRANSFORMATION

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  • UTIU reserves the right to restrict participation of anyone it deems not reasonably capable of undergoing the services of UTIU.

    The Client is to ensure the Client is available at the Client's session start time. If

    the Client is running late, please let UTIU know as soon as possible. UTIU will do his/her best to make a full session available, however, as the ability to do this will depend on bookings after the Client's session, this cannot be guaranteed.

    If the Client does not attend the session within 20 minutes of the appointed time,

    the session will be considered utilized. No refunds will be issued for cancellations

    within 48 hours of in-person sessions or 24 hours of online sessions.

    Session fees are for UTIU's time and professional expertise and are not a guarantee of a successful outcome. Therefore, no refunds will be given for any sessions where the Client has attended and paid for the session.

    Where a program has been booked and paid for in advance, if the Client choose's to discontinue the process before attending all the sessions, a pro rata refund will be issued after deduction of the full standard session fee for any sessions the Client has attended, plus any administrative costs.

    I understand that although therapy/ coaching/ consultation/ Rapid Transformational Therapy® has an incredibly high success rate, UTIU cannot depends and does not guarantee results since my own personal success on many factors that UTIU has no control over, including my willingness and desire to effect the changes inside myself.

    Audio Recording(s) and Copyright

  • UNLEASH THE INNER U REALIZATION TO TRANSFORMATION

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  • I give UTIU full permission to make audio recordings that may include My voice. I understand that if a recording (or recordings) is made during or after my session(s) UTIU retains full copyright over any forms of media that may be produced

    I understand UTIU may share with Me many material, written, audio, multimedia, etc. These are the copyright of UTIU.

    Hypnotherapy recordings should not be listened to whilst driving, operating machinery or undertaking any other activity where concentration is required. Any recording provided is for the Client's personal use only and must not be shared, lent, copied or sold under any circumstances.

    I hereby grant permission to. UTIU to respectfully lift my arm/hand, touch my shoulder, or rock my head during my Therapy session(s) in order to help facilitate the deepening process, during in person sessions.

    In case of in person sessions, I agree to be respectful, treat the premises, the people with respect. I will not vandalize, damage, destroy, misuse, abuse any of the property in the studio, office, clinic or other location specified as the location of the in person session. In case there is a damage, I am willing to pay a reasonable amount for the repair, loss, damage done. I will also not cause any harm to myself

    Release of Liability and Waiver of Claims

    I, along with my survivors, heirs, successors, assigns, executors, and personal representatives, hereby waive and release, covenant not to sue and forever discharge UTIU, and all of their respective parent and subsidiary companies, or other affiliated entities, , and all owners, shareholders, officers, directors, members, managers, employees, staff,

  • UNLEASH THE INNER U REALIZATION TO TRANSFORMATION

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  • affiliates, agents, contractors, sub-contractors, landlords, tenants, representatives, volunteers and successors and assigns, and/or any participant, from any and all liabilities, claims, suits, demands, actions, causes of action ,damages, costs and expenses of any nature whatsoever, including attorney's fees and costs (herein collectively referred to by the term 'claims'), arising from or in any way under any theory whatsoever, related to my participation/or presence on the premises/or during a virtual meeting, and including without limitation any loss, physical or emotional injury, damages, expenses, permanent disability or death suffered by me.

    On behalf of myself and on behalf of my heirs, representatives, I agree to indemnify, defend and hold harmless any and all parties from any and all claims, actions, causes of action, suits, liens and any other proceedings, arising from or in any way related to my participation in the activities of UTIU, including without limitation any loss, physical or emotional injury, pain and/or suffering, partial or permanent disability or death.

    Confidentiality Additional Provisions

    I agree to the following additional provisions: (a) I understand that the services of UTIU do not have medical personnel or treatment available to its Clients. I hereby authorize and grant permission to UTIU and its staff to secure emergency medical treatment for Me if necessary. I agree to be responsible for any and all costs of my medical and related health care of any type or nature, and for however long necessary, including, but not limited to transportation, ambulatory services, procedures, treatments, hospitalization aftercare, for myself, and that I am otherwise covered by adequate medical health insurance to provide for any medical costs that may be incurred. (b) I agree that any dispute, including any lawsuit brought by Me arising

  • UNLEASH THE INNER U REALIZATION TO TRANSFORMATION

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  • out of or relating to this Agreement or in connection with my participation with UTIU shall be governed by the laws of the State of New York, without regard to conflicts of laws principles that would require the application of any other law. I also hereby waive the right to trial by jury. (c) I agree that if any portion of this contract is determined to be unenforceable by the court, the remainder of this contract shall remain in full force and effect. The contract will apply to all interactions made by Me after its execution, provided however, that newer contracts may be executed in the future which will apply to interactions thereafter. (d) Under no circumstances will UTIU be liable for any damages, including without limitation, direct, indirect, incidental, special, punitive, consequential, or other damages (including without limitation lost profits, lost revenues, or similar economic loss), whether in contract, tort, or otherwise, arising out of the advice or information provided to you during professional services provided by UTIU. In addition, I agree to defend, indemnify, and hold UTIU harmless from and against any and all claims, losses, liabilities, damages and expenses (including legal fees) arising out of My participation in the professional services.

    By signing this form, I consent that UTIU may release information to a specific individual or agency if it has been determined that a vulnerable person (child or adult) is at risk; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.

    All contact, including sessions, telephone conversations and emails, will be conducted in confidence and may be recorded. All recordings, conversations and notes will remain confidential, except in the following circumstances:

    1.Where the Client gives permission for confidentiality to be broken

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  • 2. Where the therapist is compelled by a court of law

    .Where the information is of a nature that confidentiality cannot be maintained, for example: The possibility of harm to the Client or others exists In cases of fraud or crime When minors (under 18 years old) are involved

    4. Where a referring GP or other healthcare professional requires a report. A copy of the report will be made available on request (a fee of $100 per report is applicable)

    I also understand that, at any time, UTIU may discuss aspects of my case with other colleagues, keeping my full name and identity completely confidential always unless I have given permission otherwise. I also agree to testimonials with my name kept confidential (testimonials may be written or verbal or videos or images

    Ihave read the Disclaimer form and agree to sign it (electronically or physically):

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  • (If Client is a minor, then Parent/Guardian (referred to as P/G) Full Name and Signature) (P/G agrees for therapist to contact the minor client directly during the course of therapy)

    Please note therapy sessions are unable to begin until this document is signed and submitted to the therapist (preferably Electronically or Email or What's App/iMessage or hand delivery), as is.

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