What is your occupation?
What is the main "problem" or challenge you would like to
resolve?
You will know that this "problem" has had some
resolution when...
Complete resolution to this "problem" would
be...
DISCLAIMER
The Rejuvenation Station,
LLC, Jan Luther and Robert Leas (hereinafter referred to as “TRS, LLC”) make no claims,
implied or otherwise, regarding the success and/or results from the application
of EFT, TAT, REIKI and/or personal coaching/counseling (hereinafter referred to
as “services”) provided by TRS, LLC. These services are considered experimental
and although success rates are in the 80%-90% range, they are as yet
undocumented therapies. Robert Leas is NOT a licensed physician, therapist or
psychologist. The emotional
or physical frailty of some people is such that they should not attempt ANY
healing procedure without the presence of a LICENSED THERAPIST. This may be 2%
- 3% of the population. If you are in this category, YOU MUST
BE ACCOMPANIED BY YOUR MENTAL HEALTH CARE PROVIDER! You take full
responsibility for your personal health and safety . Your compliance
with all of your current medical treatments, therapies and prescriptions is
expected. TRS, LLC, shall not be liable for any damages or injury arising
out of your access to, or inability to access, the services provided. TRS, LLC,
disclaims any and all liability for direct, indirect, incidental, consequential,
punitive and special or other damages, lost opportunities, lost profit or any
other loss or damages of any kind.
RELEASE
By submitting this form, I
affirm that the information I have provided above is accurate and true and that
I freely enter into this legally binding agreement and acknowledge that I
understand and agree with the disclaimer presented above. Also by submitting
this form, I, and my heirs, in consideration of my participation in the services
provided by Robert Leas, Jan Luther and/or The Rejuvenation Station, LLC, hereby release Jan
Luther, her family and the officers, employees and agents of The Rejuvenation
Station, LLC , from any and all liability for any loss or damage caused, or
alleged to have been caused, directly or indirectly, by the services provided
and/or the information or ideas contained, suggested or referenced during the
course of the services provided. I understand that my participation in the
services provided is strictly voluntary, at my own risk and I freely choose to
participate. I understand that Robert Leas, Jan Luther and The Rejuvenation Station, LLC, do
not provide medical treatments and/or coverage and I verify that I will be
responsible for any and all medical costs I incur, directly or indirectly, as a
result of my participation.
AGREEMENT TO TERMS & CONDITIONS
Please enter the word
Yes
(just as it appears here)
in the box to the left to indicate that you agree to the terms and
conditions set forth above and release Jan Luther and The Rejuvenation Station, LLC from all liability,
now and in the future.
You must have a scheduled session with Bob in
order to submit this form. Please ensure you have filled in the date of
your scheduled session in the space below (use the MM/DD/YYYY format for your
entry).
Your Session Date (use the MM/DD/YYYY format) This
is a required field.
By clicking on the Submit Form button below,
you are indicating that the information
you have provided is complete and correct to
the best of your knowledge.