I, (The Client), hereby release Erik Dmitriy Palatnik (The Life Coach and Hypnotherapist) from any liability or claims that could be made against him 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 Erik Dmitriy Palatnik is not a licensed physician, psychologist, psychotherapist, or medical practitioner of any kind and that neither life coaching, nor hypnosis should be considered a replacement for the advice and/ or services of a psychiatrist, psychologist, psychotherapist, or doctor. I also understand that neither life coaching, nor hypnosis is a substitute for any medication.
I give Erik Dmitriy Palatnik full permission to hypnotize me and to use Rapid Transformational Therapy (RTT®) knowing that by participating fully in the process and by listening to my personalized recording for 18-66 days as this is scientifically proven to be the time required for the mind to inhabit new behavior and I understand that I play an important role in my overall success.
I understand that although Rapid Transformational Therapy has an incredibly high success rate, Erik Dmitriy Palatnik cannot and does not guarantee results since my own personal success depends on many factors that Erik Dmitriy Palatnik has no control over, including my willingness and desire to affect the changes inside of myself.
I give Erik Dmitriy Palatnik 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), Erik Dmitriy Palatnik retains full copyright over any forms of media that may be produced and distributed to me.
Deepening Process (in-person)
I hereby grant permission to Erik Dmitriy Palatnik 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.
By signing this form, I consent that Erik Dmitriy Palatnik 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, Erik Dmitriy Palatnik may discuss aspects of my case with other colleagues, keeping my full name and identity completely confidential always, unless I have given permission otherwise.
Cancellation and Refunds
I accept that all appointments not canceled within 48 hours’ notice will be charged in full. I also understand that my investment in this RTT® session is non-refundable.
I CONFIRM MY ACCEPTANCE OF THIS WAIVER BY CHECKING THE BOX IN THE CLIENT’S INTAKE FORM.