Emotion Code Intake & Agreement Form

Name

First NameLast Name

Today's Date

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your occupation?

What is your age?

What is your relationship status?

Are you pregnant?

Do you have any biological children?

Do you have a pacemaker or anything that would preclude the use of a magnet?

Please list the health concerns you wish to address with Emotion Code.

Please list any physicians or therapists that you are presently involved with.

Please list any serious hospitalizations, injuries or traumas.

How did you hear about Emotion Code?

I the client ( Emotion Code recepient) agree to the following:

I, the Client, understands that the role of the Lara Hinds as an Emotion Code Practitioner is not to prescribe or assess micro- and macronutrient levels; provide health care, medical or nutrition therapy services; or to diagnose, treat or cure any disease, condition or other physical or mental ailment of the human body. Rather, Lara Hinds is a certified Emotion Code Practitioner trained to release blockages keeping the body from healing on its own. The Client understands that the Practitioner is not acting in the capacity of a doctor, licensed dietician-nutritionist, psychologist or other licensed or registered professional, and that any advice given by the Practitioner is not meant to take the place of advice by these professionals. The Client has chosen to work with the Practitioner and understands that the information received should not be seen as medical or nursing advice and is not meant to take the place of seeing licensed health professionals.The Client acknowledges that the Client takes full responsibility for the Client’s life and well-being, as well as the lives and well-being of the Client’s family and children (where applicable), and all decisions made during and after this program.The Client understands that Emotion Code is not a substitute for the Client's own inner guidance and should not be viewed as such. If any recommendations are made, they are solely to be enacted at the discretion of the Client.The Client expressly assumes the risks of the Program, including the risks of trying new foods or supplements, and the risks inherent in making lifestyle changes. The Client releases the Practitioner from any and all liability, damages, causes of action, allegations, suits, sums of money, claims and demands whatsoever, in law or equity, which the Client ever had, now has or will have in the future against the Practitioner, arising from the Client’s past or future participation in, or otherwise with respect to, the Program, unless arising from the gross negligence of the PractitionerIn the event that there ever arises a dispute between Practitioner and Client with respect to the services provided pursuant to this agreement or otherwise pertaining to the relationship between the parties, the parties agree to submit to binding arbitration before the American Arbitration Association (Commercial Arbitration and Mediation Center for the Americas Mediation and Arbitration Rules). Any judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. Such arbitration shall be conducted by a single arbitrator. The sole remedy that can be awarded to the Client in the event that an award is granted in arbitration is refund of the Program Fee. Without limiting the generality of the foregoing, no award of consequential or other damages, unless specifically set forth herein, may be granted to the Client.This agreement shall be construed according to the laws of the State of Texas. In the event that any provision of this Agreement is deemed unenforceable, the remaining portions of the Agreement shall be severed and remain in full force.

Signature