Client Agreement Form

Please use the ONLINE form below to fill out and submit your Client Agreement, Disclosure, Waiver and Release form.  You can also DOWNLOAD & PRINT OUT the form and either send it in or bring it with you to your session.

CLIENT AGREEMENT, DISCLOSURE, WAIVER AND RELEASE FORM

All information is completely confidential and will not be shared without written consent.

THIS AGREEMENT is between the Client, named below, and Rajiv Parti, Certified Hypnotist/Past Life Regression Healer, at Wake Up Now, Inc., and includes the following confidential forms and services as applicable:

  • Client Consultation
  • Client Agreement, Disclosure, Waiver and Consent Form
  • Client Intake Profile Form
  • Client Sessions via Office, Phone or Video Call
  • Email or Text Check-In Between Sessions

METHODOLOGY:

Hypnotherapy is designed to benefit you, as a unique individual, and help you discover insights, create a new mental model, and develop new skills and practices toward your optimal outcomes.

The principles and theories of hypnotherapy is based upon accessing and utilizing the power of one’s inner resources. Hypnosis can transcend the critical, analytical level of mind, and facilitate the acceptance of suggestions, directions, and instructions desired by the Client. The therapeutic use of hypnosis can also elicit information and insights from the inner mind.

Past-Life Regression is designed to benefit you, as a unique individual, and help you discover insights, create a new mental model, and develop new skills and practices toward your optimal outcomes.

Past-Life Regression can involve the use of a variety of techniques in combination with progressive relaxation, hypnosis, guided imagery, facilitated fantasy, and other hypnotic interventions.

As a part of Past-Life Regression, clients are encouraged to recall, imagine events, circumstances, behaviors, thoughts, and feelings, from prior situations in their experience.

I understand clients vary greatly in their response to the relaxation/hypnosis and regression process, with some clients experiencing intense images and recollections while others report experiencing relatively little. Additionally, I am aware that the images/recollections experienced during Past-Life Regression may be real, maybe fantasy, or maybe a combination of real and fantasized or distorted memories. I also understand that certain memories or images experienced during Past-Life Regression may represent traumatic events, which can evoke intense emotional reactions or distress. These emotionally charged images are often quite useful therapeutically for facilitating insight, understanding, and healing, but such intense experiences can nonetheless be emotionally troubling.

I understand and agree that the major purpose of this program is for Vocational or Avocational Self-Improvement and those problems of psychogenic or functional origin are treated by psychological or medical referrals only (Business and Professions Code 2908, also see disclaimer below).

SESSIONS:

Hypnotherapy or Past Life Regression sessions are conducted in person, by video, or by phone. Generally, one-hour sessions are scheduled weekly and continue until you feel you have reached the level of competence over new skills, attitudes, beliefs and actions to continue the work without guidance.

You are responsible for initiating your session. Please be on time for your office visit. Call or connect with me at 408-341-9170 at your appointment time. If you are late for your appointment, your session will be shortened accordingly. If I am late, I will add additional time to the session.

Sometimes a session conducted online or by phone may get interrupted because of signal transmission failure. In those circumstances, a reconnection will be tried but if unsuccessful a client can end the trance by simply opening their eyes and counting upwards to five. In case of any adverse reaction, the client should seek appropriate medical or psychological help if it becomes necessary. You will be partially credited for the session and we will reschedule the remainder.

SCHEDULING:

Sessions may be scheduled with Rajiv Parti at a mutually agreed upon time. Consistency is key to achieving your goals, so, whenever possible, choose a day and time that works for you on an ongoing basis.

CANCELLATION POLICY:

With sufficient advance notice, we can reschedule any appointment without penalty. If you have an emergency, we’ll work around it. If you must cancel a session, we will start the next session at that point in the protocol. Missing an appointment without 24-hours advanced notice is considered a billable hour and will be deducted from your pre-paid Consulting package or billed at the hourly rate.

FEES:

Sessions are billed at $100 per hour. Pre-paid packages may be purchased as follows:

  • One-month package* – (4) four weekly 1 hr. sessions: $350
  • Three-month package** – (12) twelve weekly 1 hr. sessions: $1000

If financial circumstances make it a burden to pay the full rate, please discuss with Rajiv Parti, so that an appropriate rate may be established for you.

* One-Month Package of Sessions (4 sessions) must be completed within a 3 month time-frame.
** Three-Month Package of Sessions (12 sessions) must be completed within a 5 month time-frame.

PAYMENTS:

Payments may be made online at https:// rajpartimd.com/payment/ through the secure PayPal service or in the office through credit or debit card. Payments are due at the beginning of each session, or may be pre-paid as part of a Consulting package.

HYPNOTIST/PAST-LIFE REGRESSION HEALER COMMITMENT:

Rajiv Parti promises to co-create a partnership with you, with the intention of supporting your desired outcomes. Throughout your working relationship, you will continue to engage in very direct and personal conversations. As a hypnotist/Past-Life Regression Healer, Rajiv Parti will be honest and straightforward, use interviews, discussion, and hypnotic methods to deal with underlying issues with the goal of achieving effective and lasting results. The purpose of these interactions are to move forward with your goals as well as to deepen your learning and motivation while implementing strategies and practices for optimal outcomes.

CLIENT COMMITMENT:

It is agreed that the client is fully responsible for his or her well-being, including his or her choices and decisions. He or she is directly responsible for any outcomes achieved or not achieved and Rajiv Parti is not liable for your specific outcomes. There are no guarantees!

CONFIDENTIALITY:

All information provided to Rajiv Parti will be kept strictly confidential unless authorized by the client in writing or when federal laws have been violated. You may discuss explicit and specific personal information. Rajiv Parti respects your willingness to be truthful, and will treat this information with the utmost of confidentiality. From time to time, certain topics may be anonymously and/or hypothetically shared with other hypnotherapy professionals for training and/or consultation purposes.

Clients who choose to communicate with me via the Internet recognize that privacy rights cannot be guaranteed as they may be intercepted by a third party.

TRAINING:

Rajiv Parti obtained his medical degree from Delhi University, India. On migrating to the United States in 1982, he did his residency in Pediatrics and Anesthesiology and became Board Certified in both. He served as Chief of Anesthesia at Bakersfield Heart Hospital for over 15 years.

Rajiv has acquired the following training and qualifications, which he brings to his experience as a Certified Hypnotherapist:

  • Palo Alto School of Hypnotherapy
  • Hypnosis Pain Institute
  • Institute for Transpersonal Studies
  • Motivation and Hypnosis Institute
  • Past Life Regression Training with Brian Weiss, MD
  • Coaches Training Institute – Certified Life Coach
  • High Performance Coaching Institute
  • Chopra Center – Certified Instructor
  • Mars Venus Coaching

DISCLOSURE STATEMENT:

Past-Life Regression and Hypnotherapy are unlicensed, non-clinical, non-diagnostic and do not address the client’s mental or physical health needs. The services offered by Rajiv Parti are alternative or complementary to the healing arts services that are licensed by California.

The California State Legislature has determined that state licensing may not be conferred upon an occupational group for purposes of status or prestige. The primary purpose of licensing laws for legally defined Healing Arts and Mental Health professionals is to protect public health and safety. Accordingly, Hypnotherapists are not issued licenses by any state governmental agency to engage in their professional services.

Rajiv transitioned from his medical career after a health crisis and near death experience. Since that time, he has studied alternative health modalities and incorporates them into his Hypnotherapy/Past-Life Regression Healing practice. Rajiv Parti is not licensed by the State of California as a psychologist, marriage and family therapist, clinical social worker, or professional clinical counselor and is not currently practicing clinical medicine. He no longer practices Western medicine and his medical license is inactive.

Rajiv Parti does not offer medical, psychological, psychotherapeutic or professional clinical counseling services. Rajiv Parti does not assess mental health and does not employ counseling interventions, psychotherapeutic techniques, or other methods that would require a license.

Services offered by Rajiv Parti do not replace medical care by a physician or replace care for emotional or mental health issues by a licensed mental health care provider. The services provided by Rajiv Parti are not licensed by the State of California. If I have a psychiatric condition or need medication, I will contact my primary care or other appropriate licensed health care provider. Rajiv Parti may refer me to other providers or may refuse to provide services if he believes that I should see a licensed health care professional regarding my condition.

WAIVER, RELEASE, AND ASSUMPTION OF RISK:

This form is an important legal document. It explains the assumption of any and all risks in deciding to follow the advice or insight from Dr. Rajiv Parti, CHt who operates as a Hypnotherapist, Past-Life Regression Healer, and NLP coach. It is critical that you read and understand this waiver completely. After you have done so, please check the box that states “I have read and agree to the Waiver Release and Assumption of Risk” prior to signing the agreement.

Waiver, Informed Consent, and Covenant Not to Sue

I hereby acknowledge I have volunteered to participate in a paid or unpaid session, class, workshop, service or program with Dr. Rajiv Parti to include, but also may not be limited to, any and all services provided, such as hypnosis, Past-Life Regression, NLP, intuitive coaching, guidance, classes and workshop attendance. I do here and forever release and discharge and hereby hold harmless Dr. Rajiv Parti and his respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in a session or purchase of any program WITHOUT LIMITATION, WHICH MAY OCCUR AS A RESULT OF following advice tendered and released or training rendered or use of facilities during a session or event.

I recognize that in no way does Dr. Rajiv Parti or his representatives provide legal, medical, or therapeutic advice and it is my responsibility to secure such advisement. I acknowledge and agree that I assume the risks associated with any and all activities, offerings, services, classes and/or programs in which I participate.

I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from any insight, guidance or program. I understand that results are individual and may vary.

CLIENT INFORMATION

Best Contact for Phone Number - please include Country code if outside USA

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST LIFE SYSTEM SERVICES FOR YOUR NEGLIGENCE OR THAT OF YOUR EMPLOYEES, AGENTS, OR CONTRACTORS.

SIGNATURES:

Client Signature: Sign below

Date: 11/13/2019

I, Dr. Rajiv Parti, have explained this CLIENT AGREEMENT, DISCLOSURE, WAIVER AND RELEASE FORM, answered all of the client’s questions, informed the client of financial aspects and obligations of our agreement and that sessions are conducted by me as a Hypnotist/Past-Life Regression Healer and NOT as a doctor or medical provider.

Signed: Dr. Rajiv Parti Date: 11/13/2019

If you have completed this form and would like to complete your Client Information Profile form, CLICK HERE.

Otherwise you can return to the Services Information Page.