Holistic Wellness 4 Life
Client Agreement
Contract
All clients who participate in ayurvedic counseling program, or any health program
offered byXXX LLC (“HW4L”), acknowledge and agree to the
following:
a. I have purchased: The HW4L Ascension Program is for (4 months)
(12 months)
b. This service intends 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
i. Pre-scheduled 60–75-minute Elevation, Assessment + Planning
session, 50-minute bi-weekly Coaching sessions over the course of 4
months, and
ii. 30m Integration Session scheduled every two months during the
program duration.
iii. Final 15-30 min integrated and evaluation call.
e. HW4L includes the following: Thursday option to use Voxer as a means to check
in and ask questions. The client can leave a message at any time.
Response window (responses designated within office hours) between 10-1 pm.
If messages are outside the window time frame, a reply will be offered the
following week/day of determined hours.
f. Additional offers that may be optional include: Pre-recorded learning
sessions , exercises , and other available HW4L resources deemed
needed to best support you
1. Term.
The engagement of mentoring services begins on , and ends on
.
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2. Payments.
Payments are made in full when booking an appointment and ordering herbal
preparations. A 50% deposit can be made when booking a session, and the
remainder will be due at the start of the scheduled service date to not be more than two
(2) weeks from the date to start. Payment is accepted in cash, check, Venmo, Apple Pay,
and square.
3. Late Payment.
In the event payment is more than three (3) days late, a late fee of $200 will be
incurred. All sessions will be suspended until payment is made in full.
4. Refund/Multiple Payments.
HW4L does not offer refunds. The client agrees to pay the total amount due
. Suppose the option of a 50% deposit has been determined, and the client
becomes dissatisfied with the services or products after partial payment. In that case,
the client agrees to pay the total fee agreed upon. If the client becomes dissatisfied
with HW4L’s services or products, they are still required to pay the total due.
5. 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.
b. I agree to Pay: A total amount of in full.
c. Payment due by: The first payment is due immediately for a valid contract. Any
subsequent payments will be auto-charged regularly on the 1st of each month until
the total payment is received.
d. The Ayurveda System-based health and healing practice uses methods that
are known as alternative, holistic, or complementary systems of health.
Ayurvedic health 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,
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creating an interactive professional relationship in the healing process.
e. I am responsible for filling out the attached forms honestly, which means
providing my Ayurvedic Practitioner with truthful 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 health and the results of any
sessions provided by HW4L that may affect my health.
f. Some Ayurvedic therapy sessions may cause deep relaxation resulting in
temporary, short-term drowsiness and/or disorientation. My sole responsibility is 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.
g. 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.
h. HW4L may check my pulse and other vital signs and perform specific examination
techniques 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.
i. 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 prescribed to me by a licensed medical
professional and follow his/her instructions unless I choose to do differently.
j. Health Rejuvenation focuses on enhancing four dimensions of health – the
physical, emotional, mental, and spiritual- rather than on the physical body alone.
A person’s lifestyle mode, including their 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
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©Holistic Wellness 4 Life LLC 2022.
lifestyle patterns and establish more positive ones.
k. The holistic recommendations are natural to 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 and cleansing procedures, 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 the personal constitution
and the practitioner’s judgment.
l. 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 remedies 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. If in doubt, I will always consult my medical doctor.
m. 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 methods, 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.
n. 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
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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, advice, and herbal suggestions.
o. 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 suggested protocols, I will promptly inform
HW4L of this. I know 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.
p. HW4L encourages all clients to empower themselves by actively participating in
their 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 the Panchakarma systems of
Ayurveda philosophy and practices. I understand that this may result in some
bodily functions being temporarily affected due to shifting energy within my body
and that this is a natural occurrence (e.g., the release of gas from the rectum) or
is non- sexual in nature (e.g., erection in male clients). If I do not complete
the recommended internal and external therapies, HW4L will not be held
responsible for ineffective or faulty results.
q. Before accepting any services from HW4L, I understand the right to seek advice
from a lawyer, medical doctor, or consult my health insurance policy.
r. For any Holistic Wellness 4 Life services 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.
s. For any services of HW4L to visually or mentally disabled clients, the
responsibility of understanding this Consent form solely lies on the person/s
making appointments, consulting, or speaking on the phone on behalf of the above
persons.
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t. 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 physician or other healthcare
professional to whom I should always consult about my health, medical and
otherwise needs or symptom(s) that may require diagnosis or medical attention
and before starting or stopping any medication.
u. 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.
v. HW4L reserves the right to discontinue and/or refuse service at any time.
w. I have executed this Consent Form freely and willingly and understand its
contents, provisions, and implications, for now and for the future.
6. Voluntary Termination.
If, at any time, the client would like to terminate this contract voluntarily, they will be
subject to a 20% penalty for the remainder of their contract, of which the total is attached
and incorporated herein.
7. Nature and Results of the services.
The nature and expected results of the service or services that are offered are as follows;
a. The session will include a discussion of the client’s concerns and reason(s) for a
visit, the Practitioner’s assessment of the client, jointly exploring; past treatment
results, short-term and long-term treatment goals, current treatment options, and
the client’s home treatment plan. The client will receive a recommendations sheet
that includes the jointly agreed-upon home treatment plan and anticipated results.
b. Ayurvedic Consultation – After dialogue between the client and the
practitioner about the client’s health history and current healthcare goals,
recommendations will be provided based on the classical principles of Ayurveda.
This is tailored to the
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©Holistic Wellness 4 Life LLC 2022.
patient’s unique needs to assist the client in shifting from their current state of
imbalance toward their optimum balance. This may include information and
instruction on diet, lifestyle, and breathing practices, as appropriate, for
incorporation into their daily life for a specified period.
8. No Guaranty and Disclaimer.
HW4L makes no guarantees about treatment. The client agrees 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 the present client’s
treatment and shall not be relied upon to predict results for the client’s specific
situation. The results the client experience will be dependent on many factors,
including but not limited to their level of personal responsibility, commitment, and
abilities, in addition to those factors that the client and/or Company may not be able
to anticipate. As the client is aware, financial outcomes depend on many factors,
including but not limited to the client’s level of personal responsibility, commitment,
following set protocols, and abilities, in addition to those factors that the client 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.
9. Herbal Protocols.
HW4L encourages all clients to empower themselves by actively participating in their
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
but only by the consulting practitioner’s direction at the next Follow-Up Consultation
when there is a need for continuing or filling 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 the lack of outcome.
The practice of Ayurveda is subtle and works with the body to find its balance vs.
opposing.
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©Holistic Wellness 4 Life LLC 2022.
Determination of herbal protocol is an extra service provided to the client that offers the
reliability of safe. One of the company’s pillars is listening to your specific needs. We are
your herbal expert, and we will give the client exactly what they need so they can feel
safe and comfortable and that someone is monitoring them and we are in communication
with all these other professionals; The wealth of knowledge is immeasurable.
New herbs may be suggested after a predetermined time frame, and previous herbs are
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 their current state of
health after taking them for a determined time frame.
Once an invoice is sent via text using apple pay or square cash (client to confirm
preference in initial consult), the client has 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 the client will receive a text within 24 hours of
herbal arrival to arrange a date/time. Herbal orders have designated days/times to pick
up. The client will need to confirm with their practitioner a designated time that they will
pick up herbs. The client will have two opportunities to pick up herbs. The client
understands that after two attempts to schedule pick up for their herbal order, the herbs
will not be available.
10. Indemnification.
The client agrees on behalf of themselves and their 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 their own or HW4L acts or omissions, including negligence.
11. Waiver.
The client hereby waives and relinquishes 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
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©Holistic Wellness 4 Life LLC 2022.
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
mater ially 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 their use of any
HW4L equipment or facilities, and supervision received while at HW4L or any affiliated
facilities, the client’s slipping and falling while in HW4L or any affiliated facilities, and
their participation in any therapeutic care in various healing modalities.
This Agreement constitutes written consent to a waiver of trial by jury pursuant to any
applicable Missouri statutes.
12. Severability.
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, the client hereby agrees to waive any right to
trial by jury with respect to any action or proceeding:
a. brought by either the client or any other person, relating to;
i. Agreement and/or any understanding or prior dealings between the client
and HW4L.
13. Cancellation Policy.
HW4L does its best to be available to the client 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.
The client 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.
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©Holistic Wellness 4 Life LLC 2022.
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.
14. Late Arrival and No Show.
a. If the client shows 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 the client does not reschedule within the required time frame and does not show
up at the scheduled time, the client will forfeit the service that was to be provided
at that time, and the client 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.
d. Text messages may be used for immediate calls to action: running behind for an
appointment, requesting a different product be used for health reasons in a
session, changes in herb orders, and emergency reasons. Long extended text
messages and topics unrelated to the client’s requested service needs in relation
to health will not be able to be answered, and the client will be billed on a
prorated basis if it continues. Suppose the client’s program includes voxer
designated times. In that case, this will be the designated opportune time
included in the program to discuss all relevant information in gaining support
throughout the program and will be the primary means of communication outside
of scheduled 1-1 sessions. Emails and texting less than 10 minutes are usually
at no cost. However, if parties spend more than 10 minutes per week on the
phone, if the HW4L leaves the client for more than 10 minutes of phone
messages, or if they need to spend more than 10 minutes per week reading and
responding to emails, the client will be billed on a prorated basis for that time.
*Please allow 24 hours for a response to voice messages and email inquiries. If the
client requires a faster response or needs assistance outside of office hours, they
should send both an email and leave a voice message specifying this. Text
messages will not be an
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©Holistic Wellness 4 Life LLC 2022.
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