HYPNOSIS RESERVATION FORM / DR ROBERT ALLEN FAHEY / FORT MYERS HYPNOSIS / 239-244-1262

Welcome!

RESERVATION APPLICATION FORM PG-2009-09-01 FOR PRIVATE & GROUP HYPNOSIS AND OR LIFE COACHING INCLUDING THE GIFT GALLERY EVENT— CLIENT INFORMATION:

CLIENT/ATTENDANT must be of legal age All signatures to this Reservation Form must be affixed personally

DATE: / / 20____ NAME _______________________________________________________________

ADDRESS ______________________________________________________________________________

CITY ______________________ STATE ______ ZIPCODE _________ PHONE ( ) _______________

CELL ______________ EMAIL ADDRESS ___________________________________________________

I desire _____ a Private Hypnosis Session / Life Coaching $200.00 per person (30-minutes)

I desire _____ to make Reservations for a Series of Educational Hypnosis Sessions

I desire _____ Life Coaching Session (Reason _____ Personal _____Business _____Academic Success)

I desire to Attend _____ a Group $150.00, Per person

EFFECTIVE JULY, 2009: The current fee to Star Host a business, community or private home gallery event is $1,500.00 for up to ten (10) persons. Open galleries may include an unlimited number of guests

Agreement: The Reservation Form is a requirement to reserve a private or group educational hypnosis and or life coaching lecture appointment with the Rev. Dr. Robert Allen Fahey. Please take your time when completing this form as your answers are important to us. When completed, please deliver it personally or email it to us for approval and acceptance to drfaheyspeaking@yahoo.com. Confirm your Reservations with payment in full prior to making your first appointment. Thank you and welcome to the world of self-improvement through educational hypnosis, life coaching, and spiritual services.

This Reservation agreement explains the rights and obligations that will exist between you, the Rev. Dr. Robert Allen Fahey and BioHealth Counseling Center, Inc., including any staff members. Please print clearly in all spaces provided. Reservation Forms that are unclear will be returned.

IN CONSIDERATION of BioHealth Counseling Center, the Rev. Dr. Robert Allen Fahey, and D/B/A Websites, the CLIENT, ATTENDANT, Customer, VENDOR agree as follows:

1. CLIENT, ATTENDANT, Customer, VENDOR is of legal age in the Country and/or State in which he/she enters this agreement (if minor the parent or guardian signature is required). He or She consider themselves to be an independent moral person in society and responsible for their own health and well being, positive motivation, study habits, thinking, and understands that by applying for an educational hypnosis and or life coaching hypnosis session and or lecture series or becoming involved in any of the private and/or group educational hypnosis and or life coaching services presented by the BioHealth Counseling Center, Inc., its staff members including the Rev. Dr. Robert Allen Fahey, does NOT mean they are in any way to become an employee or legal representative for the BioHealth Counseling Center, Inc., or of the Rev. Dr. Robert Allen Fahey.

2. CLIENT, ATTENDANT, Customer, VENDOR understands they are responsible for the full cost of the private or group educational hypnosis and or life coaching session(s) or lecture series being provided and if required any Federal and State taxes and/or licenses.

3. CLIENT, ATTENDANT, Customer, VENDOR agrees to use his/her best efforts to apply any part of the educational hypnosis and or life coaching informational session and or lecture series to bring about only positive conditions for common logical and moral sense motives.

4. CLIENT, ATTENDANT, Customer, VENDOR understands that the only expense incurred for the private or group educational hypnosis and or life coaching session(s) and or lecture series being offered is the cost of the time of service being provided. Purchase of optional items, books, pendulums, certificates if presented and wanted by the CLIENT, ATTENDANT, Customer, VENDOR can be obtained for a fee, but are NOT required.

5. The BioHealth Counseling Center, Inc., and/or the Rev. Dr. Robert Allen Fahey agree to make available in advance only a mutually agreed upon prescheduled time to the CLIENT.

6. This agreement once signed, submitted and accepted will become irrevocable by the CLIENT, ATTENDANT, Customer, VENDOR.

7. CLIENT, ATTENDANT, Customer, VENDOR acknowledges that the private or group educational hypnosis and or life coaching session(s) and or lecture series being provided whether performed LIVE, through telephone conference, via the Internet or in any other form does NOT provide and or teach the CLIENT any medical and or psychological services nor does it teach the CLIENT how to provide any medical and/or psychological services.

8. CLIENT acknowledges that BioHealth Counseling Center, and it staff including the Rev. Dr. Robert Allen Fahey is NOT a medical service or doctor, but rather and educational counseling service.

9. This agreement between the CLIENT, ATTENDANT, Customer, VENDOR and BioHealth Counseling Center, Inc., its staff including the Rev. Dr. Robert Allen Fahey will be governed by the laws of Florida.

10. This agreement shall be deemed accepted by the BioHealth Counseling Center, Inc., its staff members including the Rev. Dr. Robert Allen Fahey upon issuance to the CLIENT, ATTENDANT, Customer, VENDOR of his or her reservation approval and acceptance letter, date, and/or time of private or group educational hypnosis and or life coaching appointment, and or the delivery of appointment materials.

11. CLIENT, ATTENDANT, Customer, VENDOR understands in applying for any private or group educational hypnosis and or life coaching session(s) and or lecture series, he/she pledges NOT to use such information on themselves or any other person for any medical or psychotherapeutic purpose requiring the supervision or assistance of a physician, dentist, qualified psychologist or other health practitioner unless he/she is working directly under such professional and strictly within the supervision practitioner’s area of competence. The CLIENT, ATTENDANT, Customer, VENDOR will NOT practice medicine, dentistry, psychology or offer any other professional services without proper training.

12. CLIENT, ATTENDANT, Customer, VENDOR understands that any problem of a medical or psychological nature may be treated legally only by medical doctors or other health practitioners in the healing arts. Hypnosis services may be used for therapeutic purposes only if such application is authorized by a licensed practitioner in the healing arts and only in cases in which the problem properly belongs in the specialty of the referring practitioner.

13. CLIENT, ATTENDANT, Customer, VENDOR believes that the private or group educational hypnosis and or life coaching session(s) and or lecture series he/she is seeking a reservation for can be helpful to him/her in achieving specific objectives with a twofold primary focus 1) to increase greater awareness of oneself, and 2) to enhance his/her life through general self improvement.

14. CLIENT realizes the necessity to make a sincere and full commitment to each session in order for it to be optimally effective. Also, the CLIENT assumes all risks by giving this consent, of any accident or injury prior to, during, or after any service given, and hereby release BioHealth Counseling Center, Inc., its staff, the Rev. Dr. Robert Allen Fahey from liability therefore.

15. CLIENT, ATTENDANT, Customer, VENDOR fully understands that due to individual difference in CLIENT, ATTENDANT, Customer, VENDOR commitment and participation, BioHealth Counseling Center, Inc., its staff members including the Rev. Dr. Robert Allen Fahey can make no EXPRESS or IMPLIED warranties concerning any one or more programs services being offered or presented.

16. CLIENT, ATTENDANT, Customer, VENDOR fully understands the contents in either the private or group educational hypnosis and or life coaching session(s) and or lecture series being provided may vary from any verbal communications or material given prior to, during and/or after the actual presentation and that he/she now accepts this possible fact.

17. CLIENT, ATTENDANT, Customer, VENDOR understands and accepts that hypnosis, self-hypnosis, and psychic spiritual services may be used during some parts of the services being provided and the he/she now willingly releases the BioHealth Counseling Center, Inc., it staff members including the Rev. Dr. Robert Allen Fahey from all liability as a result of any known and/or unknown mental, physical, emotional, financial, social enhancement or lack of before, during and/or after any given hypnosis, self-hypnosis or psychic spiritual services is provided except that result from wanton and willful misconduct.

18. CLIENT, ATTENDANT, Customer, VENDOR understands that the total current per person admission fee for a private educational hypnosis and or life coaching session or sitting is currently set at: $200.00 per person and each session will last approximately thirty (30) minutes. When at least three (3) sittings are purchased at one time, then each session cost is reduced to $150.00 per person who come into any one session planned, and each session will last approximately thirty (30) minutes. There is a $150.00 per person admission fee for the 3-Hour general educational combined hypnosis and self-hypnosis workshop entitled: The Gift: Success Through Positive Mental Energy, and a $1500.00 per event fee for the private home and business group educational self-hypnosis social, and when payment is made in full, it becomes automatically non-refundable and non-transferable to another person or date.

19. CLIENT, ATTENDANT, Customer, VENDOR understands that the total cost of the private or group educational hypnosis and life coaching session(s) and or lecture series being provided once paid in full will become NON-REFUNDABLE and non-transferable as explained in this reservation form agreement.

20. CLIENT, ATTENDANT, Customer, VENDOR fully understands that for any reason(s) known or unknown in advance, should he/she be unable to attend any one or group of scheduled educational hypnosis and or life coaching session(s) and or lecture series, or planned social events being offered, then he/she will automatically forfeit both the total time set aside including the time of the given Reservation the CLIENT has paid for and the total amount of the cost paid by the CLIENT, ATTENDANT, Customer, VENDOR and BioHealth Counseling Center, Inc., its staff members, including the Rev. Dr. Robert Allen Fahey will NOT be responsible in any way to make up such time or expense.

21. CLIENT, ATTENDANT, Customer, VENDOR is aware that in order for the BioHealth Counseling Center, Inc., it staff members, including the Rev. Dr. Robert Allen Fahey to service the CLIENT, ATTENDANT, Customer, VENDOR in a more efficient manner, all or parts of only the group educational hypnosis and or life coaching lecture series may be video or tape recorded for quality assurance, review purpose and quality control. Also CLIENT, ATTENDANT, Customer, VENDOR fully understands that reporters, advertising personnel or others may take publicity photos for the purpose of future articles, newspaper, radio and television promotions and gives here and now authorization and full consent and permission of release of such without any form of compensation for such testimonial and/or photos should any be taken, reviewed and looked upon as usable by the BioHealth Counseling Center, Inc., it staff members, including the Rev. Dr. Robert Allen Fahey.

22. CLIENT, ATTENDANT, Customer, VENDOR fully understands that any service provided in the private or group educational hypnosis and or life coaching session(s) and or lecture series are held out to the public as non-therapeutic, defined as the use to only inculcate positive thinking and to not ever represent any services as any form of medical health care or psychotherapy, and despite research to the contrary, by law, may make no health benefit claims for such services.

23. CLIENT, ATTENDANT, Customer, VENDOR fully understands and agrees should at any time prior to, during or after enrollment in the private or group educational hypnosis and or life coaching session(s) and or lecture series believe they already have partial or total knowledge of the content being presented, then the CLIENT, ATTENDANT, Customer, VENDOR’S participation will be considered a “self-choice” and an automatic acknowledgement that they either want or need a reinforcement and or reminder of such wisdom being given.

It is strongly recommended that the CLIENT, ATTENDANT, Customer, VENDOR be on time on the specified date and time scheduled making sure they are in full attendance. Otherwise, they will be considered a “NO SHOW.”

Your signature below indicates that you have read this entire Reservation Agreement and that you willingly accept all of the terms and conditions regarding the educational hypnosis and or life coaching session(s) and or lecture series being offered in its current version and that once you have completely filled in the required information for Reservation approval and acceptance consideration purposes and before you forward it to us, you pledge with honesty that you will to the best of your ability make a printed copy of this Reservation Form Agreement for your own personal records.

YOUR ELECTRONIC SIGNATURE (TYPE YOUR NAME HERE):

YOUR INITIALS HERE:

Note #1: Not all in attendance in private or public events are guaranteed to “feel” hypnotized.

Note #2: See Facts You Should Know About Below / Also see Terms and Conditions

FACTS YOU SHOULD KNOW ABOUT AND ACCEPT AS TRUE

1. There is a 10% refractory rate in hypnosis. What this mean is that 10 percent of the population will NOT go into hypnosis for reasons known or unknown at the time of induction.

2. A major portion of CLIENTS that apply for educational hypnosis and or life coaching sessions and or lecture series do so for self-improvement purposes only.

3. Some CLIENTS who make Reservations for educational hypnosis and or life coaching sessions and or lecture series are able to hypnotize others easily, but for one reason or another will NOT allow themselves to go into hypnosis for known or unknown reasons.

4. Some CLIENTS who make reservations for private of group educational hypnosis and or life coaching sessions and or lecture series say they never once felt hypnotized. YOU could be one!

WRITE/TYPE YOUR INITIALS HERE:

Do you have any questions or concerns about the educational hypnosis and or life coaching sessions and or lecture series being presented? If so, please ask all of them PRIOR to completing and sending in your Reservation Form. Thank You.

List by NUMBERS what area(s) of your life you desire to achieve a greater awareness of making your first choice, NUMBER 1, needing the most attention.

COLUMN #1: MENTAL _____ PHYSICAL _____ SPIRITUAL _____ FINANCIAL _____

SOCIAL _____ HOME & FAMILY _____

COLUMN #2: Stop Smoking _____ Lose Weight _____ Control My Temper _____

Reduce Stress _____ Think More Positively _____ Become Motivated _____

Be a Better Speaker _____ Be Self-Confident _____ Be More Aggressive _____ Overcome Shyness _____ Think and Grow Rich _____ Overcome Fear _____

COLUMN #3: Improving Communications _____ LEADERSHIP _____

STRESS Management _____ Control your DESTINY _____

Live your PURPOSE _____ CHANGE for SUCCESS _____ Balance Emotions _____ RELATIONSHIPS _____ Overcome Feeling SAD _____

Weight Loss Coaching _____ Brain Fitness Coaching _____

Wellness Coaching _____

COLUMN #4: To Think and Grow Rich _____ Improve Memory _____ Concentration _____

Improve Sales Ability _____ Organizational Skills _____ Time Management _____ Psychic Development _____ Other __________________

Please Answer The Following Questions

1. Have you ever been hypnotized? _____Yes _____No

_________________________________________________________________________________

2. What are your impressions of hypnosis?

_________________________________________________________________________________

3. Describe (in your best words) what you think or believe hypnosis is/how would you define hypnosis?

_________________________________________________________________________________

4. Are you able to visualize things or places described to you? _____Yes _____No

5. Briefly explain the ways in which you would like to change yourself or your life?

_________________________________________________________________________________

6. What are your expectations in learning about hypnosis?

_________________________________________________________________________________

7. How do you intend to use hypnosis and self-hypnosis in your life?

_________________________________________________________________________________

8. Do you have any fears or phobias; (e.g. heights, water, et cetera)?

_________________________________________________________________________________

9. Again, what are your interests or hobbies? _____________________________________________

10. How determine are you to succeed in the program? ____________________________________

LIMITS OF LIABILITY / DISCLAIMER OF WARRANTY: The BioHealth Counseling Center, Inc., staff, and the Rev. Dr. Robert Allen Fahey, have used their best efforts in preparing the material(s) to be presented. The authors and presenters make no representation or warranties with respect to the accuracy, applicability, fitness, or completeness of the contents of any given life coaching hypnosis program. They disclaim any warranties (expressed or implied), merchantability, or fitness for any particular purpose. The authors and presenters shall in no event be held liable for any loss or other damages, including but not limited to special, incidental, consequential, or other damages. As always, the advice of a competent legal, tax, accounting or other professional should be sought.

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