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2021 Private Session Intake Forms

Please fill out, read, and submit at least 48 hours before your appointment.

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Private Session Intake Forms

SUBMISSION GUIDELINES

FOR

RELEASE FORM

AND

HOLD HARMLESS FORM

 

Both forms must be submitted each year by the following:

Clients 18 and older

A Parent/Guardian of a Minor-aged Client

The Party Responsible for Payment

 

There are several variables here.  Please make sure all involved parties submit these forms.

 

All Clients 18 and older who are also the Party Responsible for Payment submit these forms.

 

**If the Client and the Party Responsible are NOT the same people, then the Parent/Guardian (Responsible Party) will first need to book and complete an Introductory Session and one Regular Session as a Client before I will begin working with the dependent child.  Parents, in this case, you will fill out these forms first with yourself as the Client.  Later, you will fill out these Intake Forms as a Parent/Guardian for your child after you have completed your sessions.**

 

A Parent/Guardian submits the form for a minor - aged Client only after the Parent/Guardian has completed The Introductory Session and a Regular Session.  If the Parent/Guardian is NOT the Party Responsible for Payment, then a separate form must be submitted by both parties. 

 

Parents/Guardians submit only one form for a Minor-aged child if they are also the Party Responsible for Payment.

 

 

 

Personal Information on Intake Forms

Your Information is never shared or sold!

 

Correct contact information is vital.  It is used here primarily for communicating about appointments:  questions, scheduling, appointment confirmations, rescheduling, and reminders.  Please include the client's contact information - 14 years old and older - to help make sure communication is open, up to date, and helping everyone arrive at sessions on time.

 

 

STEPS TO COMPLETE THE FORM

 

The intake system has some limitations, and therefore, you will see fields that need a duplicate answer.  In these cases, please write out the correct answer again, instead of "same as above" type answers.

Some fields may not apply to you, but you will need to read and answer those, too (write N/A in those.)

 

Please fill out all fields correctly to complete the form.

 

The Private Session Intake Forms are not complete unless you check all the boxes, including both the boxes under each Form, signifying you have read and agree to both the Release & Hold Harmless Forms.

 

Thank you for your patience!

 

 

 

Question 3 of 27

Your Email:

Question 4 of 27

Your Name:

Question 5 of 27

I am:

A

The Client- Party Responsible for Payment

B

The Client- Not Responsible for Payment

C

The Parent/Guardian- Party Responsible for Payment

D

Party Responsible for Payment - Not Guardian

Question 6 of 27

If you selected "D" above - you are NOT the parent or guardian but ARE the party responsible for payment - please state your relationship to the client:

Question 7 of 27

Is the Client a Minor-aged child? ("Yes" or "No")

Question 8 of 27

Name(s) of Parent/Guardian:  ("N/A" if it doesn't apply.)

Question 9 of 27

Email of Parent/Guardian:  ("N/A" if it doesn't apply.)

Question 10 of 27

Mobile Phone of Parent/Guardian:  (N/A if it doesn't apply.)

Question 11 of 27

Client's Name:

Question 12 of 27

Client's Age:

Question 13 of 27

Client's Date of Birth (mm/dd/yyyy) :

Question 14 of 27

Client's Email (14 & older,  put "N/A" if younger):

Question 15 of 27

Client's Mobile Phone (14 & older,  put "N/A" if younger):

Question 16 of 27

Name of Party Responsible for Payment:

Question 17 of 27

Email of Party Responsible for Payment: (please list email attached to PayPal payment here.)

Question 18 of 27

Mobile Phone of Party Responsible:

Release Form

For Private Sessions

Question 20 of 27

 

 

I, _________, understand that nothing said, done, performed, typed, printed, or produced by Peggy Nazer is intended or meant to diagnose, prescribe, treat a disease or take the place of diagnoses by a licensed physician, psychologist, or psychiatrist.

 

Consultations by phone or email, training, coursework, coaching sessions, energy psychology work sessions, Integrative Processing Technique (IPT) sessions, integration sessions, classes, or techniques are to promote healthy lifestyles and cultivate the mind/body connection.

 

A variety of non-invasive methods, modalities, and programs, commonly referred to as Energy Psychology, may be used, which include but are not limited to, bio-kinesiology (muscle response testing-MRT). MRT is used to determine past events and identify negative emotions stored in certain chakras or energy centers of the body.  Guided imagery, NLP, speaking out feelings, role-playing, inner child work, chakra work, visualization and various Energy Psychology techniques are used.  The purpose of using these techniques is to bring the client to a place of inner healing/reconciling and a strong sense of well-being and closure with the issues being addressed.

 

This form is a release form granting Peggy Nazer permission to release and clear negative energy and process my family member or me through experiences using both conscious awareness and energy release techniques.  This authorization is valid for any and all private and group sessions as well as any coursework involving Peggy Nazer.

 

(Select all that apply)
A

I agree that these Terms and Conditions apply to all of my minor-aged children

B

I have read and agree to these Terms and Conditions. I understand that submitting this form serves as my electronic signature

Question 21 of 27

Your Name:

Hold Harmless Form

For Private Sessions

Question 23 of 27

 

 

In consideration of receiving life coaching & energy psychology work from Peggy Nazer (DBA Peggy Nazer Coaching), I hereby release, waive and discharge all rights to legal action against and covenant not to sue, and agree to forever hold harmless for any and all purposes, Peggy Nazer Coaching from any and all liabilities, claims and/or demands that may result from coaching and/or energy psychology work, provided by Peggy Nazer Coaching.

 

My election to receive coaching & energy psychology work or any other services provided by Peggy Nazer Coaching is completely voluntary and at my own discretion.  I also hereby acknowledge that Peggy Nazer Coaching does not make any promises or guarantees that her methods will help or cure me of any type of condition or health problem. I voluntarily assume full responsibility for any risks or outcomes that may result from receiving coaching or energy psychology work, whether caused by commission or omission on the part of Peggy Nazer Coaching.

 

It is my expressed intent that this Covenant Not To Sue and Hold Harmless Agreement shall bind the members of my family, spouse, heirs, and their families and personal representatives.  I acknowledge and represent that I have read the foregoing Covenant and Agreement, understand it, and voluntarily agree to it, and its terms in full as my own free act and deed; no oral representations, statements, or inducements apart from the foregoing agreement that has been reduced to writing have been made.  I execute this document as full, adequate, and complete, fully intending to be bound by the same, now and in the future.

 

(Select all that apply)
A

I agree that these Terms and Conditions apply to all of my minor-aged children

B

I have read and agree to this Covenant and Agreement. I understand that submitting this form serves as my electronic signature

Question 24 of 27

Your Name:

Question 25 of 27

I am:

A

The Client - Party Responsible for Payment

B

The Client - NOT Responsible for Payment

C

Parent/Guardian - Party Responsible for Payment

D

Party Responsible for Payment - Not Parent/Guardian

Question 26 of 27

Completed Intake Forms are required from Clients 18 years and older, Parents of Minor Clients, AND the Party Responsible for Payment of Services.  Submit separate forms where necessary so that all forms are received from all required parties.

A

I understand that both Intake Forms must be submitted by clients 18 years and older, by parents on behalf of minor clients, AND by the party responsible for payment. Failure to fill out all fields and submit both forms by all parties involved 24 hours before the session will prioritize completing and submitting all necessary forms. No extra time will be allotted to the session to make up for time spent on forms.

Question 27 of 27

Please review all personal information to make sure it is correct and complete before submitting it.  Missing or inaccurate information can result in using session time to finish the paperwork.

(Select all that apply)
A

I have reviewed all information on this form and certify that it is correct and complete.

Confirm and Submit