Session Intake Form
THIS IS A PREVIEW OF THE REQUIRED SESSION INTAKE FORM.
You will be given a link to this form to submit immediately after purchase.
PLEASE READ AND MAKE SURE YOU AGREE BEFORE PURCHASING PRIVATE OR GROUP INNER DYNAMICS COACHING SESSIONS.
You must submit forms upon purchase to complete enrollment and registration.
Failure to submit Forms within 24 hours of purchase will revoke access to the group session.
**You will not receive a refund if you miss the session because of late 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.
**NOTE ON PRIVATE SESSIONS FOR DEPENDENT CHILDREN: Parent/Guardian (Responsible Party) must book and complete two Private Coaching Sessions for themselves as a Client before I begin working with their 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 two Private Sessions for themselves. 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 THIS 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.
I appreciate your patience!
(FILL-IN-THE-BLANK PERSONAL INFORMATION QUESTION FIELDS HERE).
RELEASE FORM
For Private & Group Sessions
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, private and/or group 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. In addition, 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.
HOLD HARMLESS FORM
For Private & Group Sessions
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.
ALL FORMS MUST BE SUBMITTED BY ALL INVOLVED PARTIES
All Clients 18 years and older are required to complete all Intake Forms. Parents of Minor Clients AND the Party Responsible for Payment of Services are also required to complete all Forms.
Submit separate forms where necessary so that all forms are received from all required parties.
