Cosmic Cord Center

Ordained Holistic Practitioner

Informed Consent, Private License & Release

The undersigned hereby grants a Private License to the Practitioner to provide Holistic Spiritual Counseling services to the undersigned as expressive association activities. I acknowledge that I am not receiving these services as a patient of any licensed treatment protocol.

The undersigned acknowledges that the Cosmic Cord Center Practitioner does not diagnose or prescribe for chiropractic, medical or psychological conditions nor claim to prevent, treat, mitigate or cure such conditions. The Practitioner does not provide diagnosis, care, treatment or rehabilitation of individuals, nor apply medical, mental health or human development principles, but rather provides a modality known as Holistic Spiritual Counseling that may offer therapeutic benefit by supporting normal structure and function and strengthening a spiritual connection.

The undersigned gives Informed Consent to the services that will be provided. The undersigned hereby releases the Practitioner employing Holistic Spiritual Counseling from all claims and liabilities arising from the use or misuse of such modalities, indemnifying and holding the Practitioner harmless from all claims and liabilities there from whatsoever. The Practitioner reserves all rights.