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Lynne Forrest & Conscious Living Media, LLC

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Item	Quantity	Total
Automatic Monthly Renewal: Noblemen's Group	x $250.00	$250.00 per month
Total: $250.00	Coupon:

The Reality Formula®

The Reality Formula® is a technique that utilizes basic universal principles along with intellectual tools to discover, understand, and re-frame core beliefs in order to gain a more positive perspective which is in alignment with Reality.

Waiver and Session Consent

I understand that the attending Reality Formula® coach is not a doctor (MD) and does not portray themselves to be, and that no government agency has endorsed the efficacy of such techniques.

In addition, I understand that I will not receive a diagnosis, treatment, or prescription for any disease, condition(s), or illness, or have any act performed that would constitute the practice of medicine for which a license is required. I agree that no promises as to the expected results from the Reality Formula® sessions have been made and I understand that reaching my session goals are not guaranteed.

I also understand, acknowledge, and agree that Reality Formula® coaches do not provide mental health crisis intervention or other emergency services.

I have solicited the attending practitioner’s services in good faith, exercising my free will and following the dictates of my own conscience, which allows me to select and understand what is most beneficial to my health. I am fully aware and release the Reality Formula® practitioner(s) to work with me and utilize the Reality Formula® approach.

I hereby give my full consent for the utilization of the Reality Formula® mind/body approach.

Agreement to Pay for Services

I agree to pay for un-cancelled appointments or those where I failed to to provide 24 hours notice that I will not attend. The only exceptions are for unforeseen or unavoidable emergency situations arising suddenly.

I understand that the Reality Formula® services are not covered by insurance companies and agree that I am fully responsible for payment of services received.

I am aware that I may stop my sessions at any time.

Confidentiality

I understand that what is discussed within my session(s) and the contents of my file may not be released without my prior written consent (a signed release, apart from the following exceptions: 1) suspected child abuse, 2) imminent danger to self or others, or 3) mandated by court proceedings, or 4) In workshop settings where waivers may apply.

Unless otherwise stated, I understand Reality Formula® coaches are not mandatory reporters, under any legal governing body or insurance boards and therefore are not subject nor required to report abuse, or seen as a reliable witness in a court of law, or work with insurance providers, or under HIPAA laws.

By proceeding, I acknowledge that I am over the age of 18 and that I have read, understand, and agree to all parts of this waiver.