Holistic Wellness 4 Life
Client Agreement Contract
All clients who participate in ayurvedic counseling program, or any health program
offered by Holistic Wellness 4 Life LLC (“HW4L”), acknowledge and agree to the
following:
a. I have purchased: The HW4L Ascension Program (4 mo)
b. The intention for this service is: to support the client in designing their life based on their
constitution, identify and clarify their health goals, and work to integrate and sustain lifestyle
principles.
c. HW4L does this using: coaching sessions, body/mind connection integration
sessions, Voxer support, homework, and pre-recording teaching skills.
d. This service includes the following session(s): Initial consult (1) pre-scheduled 60-75
minute Elevation, Assessment + Planning session, 50-minute bi-weekly Coaching sessions
over the course of 4 mo and (2) 30m Integration Session scheduled every 2 mo during
program duration. (1) final 15-30 min integrated and evaluation call
e. HW4L includes the following: Thursday option to use Voxer as a means to check-in, ask
questions. Client can leave a message at anytime. Response window (responses
designated within office hours) between the hours of 10-1 pm. If messages are outside of
the window time frame, a response will be offered the following week/day of determined
hours.
f. Additional offers that may be optional included BONUS: Pre-recorded learning sessions,
exercises, and other available HW4L resources deemed needed to best support you.
3. Term:
The engagement of mentoring services begins March 14th 2021, and ends March 13th,
2023.
4. Client’s Participation:
a. I agree to participate in the following way: attend all sessions, stay in communication on
helping to make changes, implement and embody lifestyle practices to best support my
desired outcome and participate in the design of the health and wellness plan.
5. I agree to Pay: A total amount of $8200 in full.
B. Due by: First payment due immediately for valid contract. Any subsequent payments will be
auto-charged on a monthly recurring basis on the 1st of each month until total investment is
received.
1. The Ayurveda System-based health and healing practice use methods that are
known as an alternative, holistic, or complementary system of health. Ayurvedic health
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©Holistic Wellness 4 Life LLC 2022.
rejuvenation is created through a partnership between ‘I as Person’ and the HW4L and its
Ayurveda Practitioners. The values of trust and mutual respect, understanding, caring, and
fairness are the cornerstones of such a partnership creating an interactive professional
relationship in the healing process.
2. It is my responsibility to fill out the attached forms honestly, which means providing
my Ayurvedic Practitioner with honest and complete information regarding my health and
well-being to the best of my knowledge. In that way, I am assuming sole responsibility for
my own health and for the results of any sessions provided by HW4L that may affect my
health in any way.
3. Some of the Ayurvedic therapy sessions may cause deep relaxation resulting in
temporary, short-term drowsiness and/or disorientation. It is my sole responsibility to advise
my HW4L Practitioner if I am experiencing these or similar symptoms. I agree to avoid
driving or operating any heavy machinery after these sessions.
4. HW4L is not a medical facility and HW4L, nor its Ayurvedic Practitioners are not
trained in medical diagnosis or treatment. HW4L does not diagnose conditions, prescribe
medications or provide medical treatments. Ayurveda is not a state-licensed healing art.
HW4L is not a state-licensed healing art professional.
5. HW4L may check my pulse and other vital signs and perform certain examination
techniques which are similar to a routine medical examination. However, these examination
techniques, and the resulting evaluations and findings, are made from an Ayurvedic
viewpoint. They do not in any way represent a traditional Western medical perspective.
6. HW4L sessions do not replace conventional medical diagnosis or treatment. I know
that HW4L is subscribing or altering my allopathy prescriptions. I will continue taking all
medications which have been prescribed to me by a licensed medical professional and
continue to follow his/her instructions unless I choose to do differently.
7. Health Rejuvenation focuses on enhancing four dimensions of health – the physical,
emotional, mental, and spiritual, rather than focusing on the physical body alone. A person’s
mode of lifestyle, including his or her diet, behavioral and exercise patterns, sleep habits,
level and amount of stress and interpersonal relationships are believed to be directly-
related to the development and maintenance of health. Ayurveda evaluates these factors
and seeks to help people give up negative lifestyle patterns and establish more positive
ones.
8. The holistic recommendations are natural to both the body and mind, focusing on
improving health. These include Ayurveda Herbs and Ayurveda oils potentiated with herbs.
My holistic recommendations may also include herbal supplements, Ayurvedic detoxification
oil applications and body techniques, Panchakarma and detoxification programs, diet
guidance, lifestyle practices, exercise routine, meditation and breathing exercises, fasting
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©Holistic Wellness 4 Life LLC 2022.
and cleansing techniques, externally applied herbal poultices, internal and external
applications of botanical products in the form of decoctions and herbal medicated oils used
as enemas, purgatives, emetics and for the general detoxification of the body, as suggested
for holistic healing. The recommendations vary depending upon personal constitution and
the practitioner’s judgment.
9. HW4L offers no warranty or guarantee of my care. Just as there may be risks and
hazards in continuing my present condition with or without conventional medical treatment,
there are also risks and hazards related to the performance of the Ayurvedic, alternative,
integrative and complementary remedy or remedies and procedure(s) planned for me.
These risks increase when not following planned protocols of care recommended to me for
my general health or during Panchakarma treatments. At all times, if in doubt, I will consult
my medical doctor.
10. I have been given an opportunity to ask questions about my condition before I book a
session with HW4L. I have also been given an opportunity to be precisely clear about
conventional therapies, integrative and complementary techniques, alternative forms of
techniques, risks of non-treatment, procedures to be used, and the risks and hazards
involved, and I agree that I have sufficient information to give this informed consent.
11. I am solely responsible for the payment of the consultation and material services
provided and I agree that I am fully aware of the cost of all services and procedures
involved. I also agree to defend, indemnify, and hold harmless HW4L and its subsidiaries,
employees, and agents of each, from and against any and all losses, claims, damages,
costs and expenses which I may be and/or become obligated to pay arising or resulting from
use of any of the suggested Ayurvedic techniques, advices and herbal suggestions.
12. Some Ayurvedic formulations contain honey, nuts and/or dairy products, eggs, soy,
wheat and other food allergens. If I do not want HW4L to use these products during my
sessions or as part of the protocols that are suggested to me, I will promptly inform HW4L of
this. I know that it is my sole responsibility to inform my HW4L Practitioner of any known
allergies, pre-existing conditions, or sensitivities to honey, nuts, dairy or any other products
where I may have an allergic reaction.
13. HW4L encourages all clients to empower themselves by actively participating in their
own well-being. This includes attending classes, workshops, seminars, follow-up visits, set
protocols recommended during panchakarma and all in-person external body therapy
treatments as part of Panchakarma which inform, educate and complete the rejuvenating
steps as part of Panchakarma systems of Ayurveda philosophy and practices. I understand
that this may result in some bodily functions being temporarily affected as a result of shifting
energy within my body and that this is a natural occurrence (e.g. release of gas from the
rectum) or is non-sexual in nature (e.g. erection in male clients). If I do not complete the
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©Holistic Wellness 4 Life LLC 2022.
recommended internal and external therapies, HW4L will not be held responsible for
ineffective or faulty results.
14. Before accepting any services from HW4L, I understand the right to seek advice with
a lawyer, medical doctor or consult my health insurance policy.
15. For any services of Holistic Wellness 4 Life to minors, the responsibility of
understanding this Consent Form lies solely on the parents, one of the parents, caretaker(s),
or guardian(s) of the minor.
16. For any services of HW4L to visually or mentally-disabled clients, the responsibility of
understanding of this Consent form solely lies on the person/s making appointments,
consulting, or speaking on the phone on behalf of the above-persons.
17. I voluntarily seek alternative-based health care services from HW4L. I hereby agree
that the alternative-based health care services are intended only to complement, not to
replace the advice of my own physician or other healthcare professional to whom I should
always consult about my individual health, medical and otherwise needs or symptom(s) that
may require diagnosis or medical attention and before starting or stopping any medication.
18. The services rendered by HW4L are traditional Ayurvedic practices. The Ayurvedic
Practitioner is not a licensed physician and the sessions are alternative and complementary
healing art services. The services rendered by HW4L are for educational purposes. The
practitioner has undergone appropriate education and training for the services rendered and
is a Licensed Dietitian.
19. HW4L reserves the right to discontinue and/or refuse service at any time.
20. I have executed this Consent Form freely and willingly, and understand its contents,
provisions and implications, for now and for the future.
Payments: Payments are made in full at the time of booking an appointment and ordering
of herbal preparations. A 50% deposit can be made at the time of booking a session and the
remainder will be due at the start of the scheduled date of service to not be more than two
(2) weeks from the determined date to start. Payment is accepted in the form of cash,
check, Venmo, Apple Pay and square.
Late Payment:
In the event payment is more than three (3) days late, I will incur a late fee of $200.
All sessions will be suspended until payment is made.
10. Refund/Multiple Payments:
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©Holistic Wellness 4 Life LLC 2022.
HW4L does not offer refunds. I agree to pay the total amount due. If the option of 50% deposit
has been determined, and I become dissatisfied with the services or products after providing
partial payment, I agree to pay the total fee agreed upon. If I become dissatisfied with HW4L’s
services or products, I am still required to pay the total due.
11. Voluntary Termination:
If at any time, I would like to voluntarily terminate my contract, I will be subject to a 20%
penalty of the remainder of my contract, of which the total is attached and incorporated
herein.
The nature and expected results of the service or services that are offered:
● A session will include a discussion of my concerns and reason(s) for the visit,
Practitioner’s assessment of me, jointly exploring; past treatment results, short-term and
long-term treatment goals, current treatment options and my home treatment plan. I will be
given a recommendations sheet that includes the jointly agreed upon home treatment plan
and anticipated results
● Ayurvedic Consultation – After dialogue between me and the practitioner about my
health history and current healthcare goals, recommendations will be provided based on the
classical principles of Ayurveda. This is tailored to the unique needs of the patient with the
intention of assisting me to shift from my current state of imbalance toward my optimum
balance. This may include information and instruction on diet, lifestyle, and breathing
practices, as appropriate, for incorporation into my daily life for a specified period of time.
16. No Guaranty; Disclaimer:
HW4L makes no guarantees about treatment. I agree that any statements made by HW4L
regarding potential outcomes are opinions and are not binding on HW4L. The testimonials
from previous clients may differ from my own treatment and shall not be relied upon to
predict results for my specific situation. The results I experience will be dependent on many
factors including but not limited to my level of personal responsibility, commitment, and
abilities, in addition to those factors that I and/or Company may not be able to anticipate.
As I know, financial outcomes depend on many factors including but not limited to my level
of personal responsibility, commitment, following set protocols, and abilities, in addition to
those factors that I and/or HW4L may not be able to anticipate. I agree that Company is not
responsible for my success, or lack thereof. My reliance on any information provided is done
at my own risk.
HERBAL PROTOCOLS
HW4L encourages all clients to empower themselves by actively participating in their own
well-being. All custom herbal protocols are intended for the stated duration of time
following a consultation only. HW4L does not refill custom herbal protocols by request
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©Holistic Wellness 4 Life LLC 2022.
but only by the direction of the consulting Practitioner at the next Follow-Up Consultation
when there is a need for continuing or refilling herbal protocols. If the herbal protocol is not
started on a planned date or is not taken according to recommended protocol, HW4L is not
held responsible for lack of outcome.
The practice of Ayurveda is subtle and works with the body to find its own balance vs
opposing upon. Determination of herbal protocol is an extra service provided to the client
that offers reliability of safeOne of my pillars is listening to your specific needs and I’m your
herbal expert and I’m going to be giving you exactly what you need so you can feel safe and
comfortable and that someone is monitoring and Im in communication with all these other
professionals.
the wealth of knowledge is immeasurable
New herbs may be suggested after a determined set time frame and previous herbs
discontinued. I understand that the importance of my health outweighs the financial cost of
purchasing herbs that may no longer be supportive or relevant to my current state of health
after taking them for a set determined time frame. Once an invoice is sent via text using
apple pay or square cash (client to confirm preference in initial consult) , I have 48 hours to
complete payment or herbs will not be ordered. All custom herbal protocols or treatments
are non-refundable and non-exchangeable. Herbs will be picked up on location and you will
receive a text within 24 hours of herbal arrival to arrange a date/time. Herbal orders have
designated days/times to pick up. I will need to confirm with my practitioner a designated
time that I will pick up herbs. I will have two opportunities to pick up herbs. I understand that
after two attempts to schedule pick up for my herbal order and then the herbs will not be
available.
I agree on behalf of myself and my personal representatives, heirs, executors,
administrators, agents and assigns, to the maximum extent allowed by Missouri law, to
release and discharge HW4L, affiliates, representatives and successors and assigns from
any and all claims or causes of action (known or unknown) arising out of my own or HW4L
acts or omissions, including negligence. I hereby waive and relinquish all rights and benefits
afforded by Section 1542 of the Civil Code of the State of Missouri, which reads as follows:
“A general release does not extend to claims which the creditor does not know or suspect to
exist in his or her favor at the time of executing the release, which if known by him or her
must have materially affected his or her settlement with the debtor.” This waiver and release
of liability include, without limitation, injuries that may occur as a result of my use of any
HW4L equipment or facilities, any supervision received while at HW4L or any affiliated
facilities, my slipping and falling while in HW4L or any affiliated facilities, and my
participation in any therapeutic care in various healing modalities. If any portion of this
Agreement is held to be invalid, the remainder shall continue in full force and effect.
To the extent permitted by applicable law, I hereby agree to waive any right to trial by jury
with respect to any action or proceeding: (a) brought by either me or any other person,
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©Holistic Wellness 4 Life LLC 2022.
relating to (i) Agreement and/or any understanding or prior dealings between me and HW4L.
This Agreement constitutes a written consent to waiver of trial by jury pursuant to any
applicable Missouri statutes.
CANCELLATION POLICY
HW4L does its best to be available to you seven (7) days a week and on holidays (during
Panchakarma procedures), and to create ample or non-rushed time with each person who
comes in our door.
I will provide HW4L no less than forty-eight (48) hours advance notice for Monday through
Friday appointments. Canceling for Monday service would need to be canceled the Friday
before.
**Cancellations are not accepted for Weekend or Holiday appointments. If a session is
canceled within forty-eight (48) hours of its scheduled time, then HW4L Life reserves the
right to charge for an amount equal to half of the cost of the scheduled session.
If a Saturday, Sunday or Holiday session is canceled after booking, then HW4L has
permission to charge for an amount equal to the cost of the session.
Late Arrival and No Show:
a. If I show up late to the scheduled session, it will be forfeited after fifteen (15) minutes.
Additional time will not be added to the end of the session in the event of late arrival.
b. If I do not reschedule within the required time frame, and does not show up at the
scheduled time, I will forfeit the service that was to be provided at that time, and I will not
receive a refund for missing the appointment.
c. Excessive changing of appointment dates/times will not be permitted and the practitioner
has the choice to discontinue services should this become the case.
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