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2022 Old Personal Success Dynamics Coaching Intake Forms

Please fill out, read, and submit.

Don't be overwhelmed by the field tally.  Each "field" is one piece of information such as "name" or "age."  These forms are easy to complete.

After you submit this form and receive an email confirmation that it is complete, click the "Purchase" button below to finish your registration.

Failure to submit Forms will result in lost access to the coaching membership portal.

 

Click the button below to start.

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2022 Personal Success Dynamics Coaching Membership Intake Forms

For Peggy Nazer Coaching

2022 Personal Success Dynamics Coaching Consent Forms

SUBMISSION GUIDELINES

FOR

RELEASE FORM

AND

HOLD HARMLESS FORM

Submit this form for each person listening to the coaching sessions or training lessons.

Families, or others listening together, should purchase a membership for each person and submit all forms for each person.  Minor-aged siblings can share a membership, so a parent or guardian can submit one form for all minor-aged children 13 and younger.  Parent/Guardian must submit a separate form for children 14 years and older.

 

As these forms are updated, they 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 to consider.  

Clients 18 and older who are also the Party Responsible for Payment

Clients 18 and older who are not  the Party Responsible for Payment (in addition, the Party Responsible also submits these forms.)

The Parent/Guardian of a Minor-aged Client

The Party Responsible for Payment (this is either the parent/guardian or another party.)  NOTE:  If the Parent/Guardian is NOT the Party Responsible for Payment, then the Responsible Party also submits the form.

 

Please make sure all involved parties submit these forms.
 

If you have any questions or concerns, please email me:

[email protected]

 

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 sessions:  questionnaires, content availability, 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 stay notified.

 

NOTE TO PARENT: A section is reserved for personal information for young Clients' (aged 13 and younger). You may fill out one form for your children 13 and younger that participate in coaching rather than fill out a form for each child.  However, you must submit a separate form for your children 14 and older.

 

STEPS TO COMPLETE THIS FORM

 

The intake system has some limitations; 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 2022 Personal Success Dynamics Coaching Consent 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 Consent Forms.

 

I appreciate your patience!

 

 

 

Question 4 of 61

Your Email:

Question 5 of 61

Your Name:

Question 6 of 61

Please state, using the exact phrases written in bold, the position that describes you best:

 

The Client - Party Responsible for Payment (You or your spouse pays for enrollment.)

 

The Client - Not Responsible for Payment (This answer typically applies when the client's enrollment is paid for by a parent/guardian. NOTE:  client's under 18 do not fill out this form.)

 

The Parent/Guardian - Party Responsible for Payment

 

Party Responsible for Payment - Not Guardian (This answer typically applies if another relative, a friend, or clergy is paying for the client's enrollment.)

 

After reading through the descriptions above, the position that describes me best is:

Question 7 of 61

If you selected "Party Responsible for Payment - Not Guardian" above - you are NOT the parent or guardian but ARE the party responsible for payment - please state your relationship to the client (N/A if doesn't apply):

Question 8 of 61

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

Question 9 of 61

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

Question 10 of 61

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

Question 11 of 61

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

Question 12 of 61

Personal Information for Client(s) 13 & younger.  If you have more than one child younger than 13 who is listening to IDC sessions, put their information on a separate line.  Fill out a separate form for all children 14 & older.

 

#1 Child's Name,  Age, Date Of Birth (mm/dd/yyyy)

#2 Child's Name, Age, Date Of Birth (mm/dd/yyyy)

 

Put N/A if this doesn't apply.

Question 13 of 61

Client's Name (14 & older, put N/A if the client is younger):

Question 14 of 61

Client's Age (14 & older, N/A if doesn't apply):

Question 15 of 61

Client's Date of Birth (mm/dd/yyyy) (for clients 14 & older, "N/A" if younger):

Question 16 of 61

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

Question 17 of 61

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

Question 18 of 61

Name of Party Responsible for Payment:

Question 19 of 61

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

Question 20 of 61

Mobile Phone of Party Responsible:

Release Form

For Personal Success Dynamics Coaching

Question 22 of 61

 

 

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, Inner Dynamics (IDC) private and group coaching sessions, energy psychology work sessions, Certified High Performance Coaching (CHPC), 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.

 

(Select all that apply)
A

I agree that these Terms and Conditions apply to all of my minor-aged children that I choose to enroll in Peggy Nazer's services and for any adult children for whom I am paying for Peggy Nazer's services.

B

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

Question 23 of 61

Type your name as it would appear on a Signed Document:

Hold Harmless Form

For Personal Success Dynamics Coaching

Question 25 of 61

 

 

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 demands that may result from coaching and 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 entirely 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 and 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 that I choose to enroll in Peggy Nazer's services and for any adult children for whom I am paying for Peggy Nazer's services.

B

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

Question 26 of 61

Type your name as it would appear on a Signed Document:

Question 27 of 61

Clients 18 years and older are required to complete all Intake Forms.  In addition, parents of Minor Clients AND the Party Responsible for Payment of Services are also required to complete all Intake Forms.  Submit separate forms where necessary so that all documents are received from all required parties.

 

Personal Success Dynamics Coaching Membership Intake Forms are due before purchase to avoid denied access.

 

(Select all that apply)
A

I understand that Personal Success Dynamics Coaching Membership Intake Forms are due before purchase to avoid denied access.

Question 28 of 61

Please state, using the exact phrases written in bold, the position that describes you best:

 

The Client - Party Responsible for Payment (You or your spouse pays for enrollment.)

 

The Client - Not Responsible for Payment (This answer typically applies when the client's enrollment is paid for by a parent/guardian. NOTE:  client's under 18 do not fill out this form.)

 

The Parent/Guardian - Party Responsible for Payment

 

Party Responsible for Payment - Not Guardian (This answer typically applies if another relative, a friend, or clergy is paying for the client's enrollment.)

 

After reading through the descriptions above, the position that describes me best is:

Question 29 of 61

Your name as it would appear on a signed document:

2022 Personal Success Dynamics Coaching Membership Policies & Procedures Agreement

For Peggy Nazer Coaching

2022 Personal Success Dynamics Coaching Membership Policies & Procedures

FORM SUBMISSION GUIDELINES

Each person listening to the coaching sessions or training lessons must have a submitted form.

 

Families, or others listening together, should purchase a membership for each person and submit all forms for each person.  Minor-aged siblings can share a membership, so a parent or guardian can submit one form for all minor-aged children 13 and younger.  Parent/Guardian must submit a separate form for children 14 years and older.

 

As this form is updated, it must be submitted each year by the following:

 

Clients 18 and older who are also the Party Responsible for Payment

Clients 18 and older who are not  the Party Responsible for Payment (in addition, the Party Responsible also submits these forms.)

The Parent/Guardian of a Minor-aged Client

The Party Responsible for Payment (the parent/guardian or another party.)  NOTE:  If the Parent/Guardian is NOT the Party Responsible for Payment, the Responsible Party must also submit a separate form.

 

Please make sure all involved parties submit these forms.
 

If you have any questions or concerns, please email me:

[email protected]

 

Personal Information

Your Information is never shared or sold!

 

Correct contact information is vital.  It is used here primarily for communicating about sessions:  questionnaires, content availability, 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 stay notified.

 

NOTE TO PARENT: A section is reserved for young Clients' (aged 13 and younger) personal information. You may fill out one form for your children 13 and younger that participate in coaching rather than fill out a form for each child.  However, you must submit a separate form for your children 14 and older.

 

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 Personal Success Dynamics Coaching Policies & Procedures Form will not register as complete unless you check all the boxes, signifying you have read and agree to all Policies & Procedures.

 

I appreciate your patience!

 

 

Question 33 of 61

Your Email:

Question 34 of 61

Your Name:

Question 35 of 61

Please state, using the exact phrases written in bold, the position that describes you best:

 

The Client - Party Responsible for Payment (You or your spouse pays for enrollment.)

 

The Client - Not Responsible for Payment (This answer typically applies when the client's enrollment is paid for by a parent/guardian. NOTE:  client's under 18 do not fill out this form.)

 

The Parent/Guardian - Party Responsible for Payment

 

Party Responsible for Payment - Not Guardian (This answer typically applies if another relative, a friend, or clergy is paying for the client's enrollment.)

 

After reading through the descriptions above, the position that describes me best is:

Question 36 of 61

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

Question 37 of 61

Parent/Guardian Name if the Client is a minor:  (N/A if it doesn't apply)

Question 38 of 61

Parent/Guardian Email if the Client is a minor:  (N/A if it doesn't apply)

Question 39 of 61

Parent/Guardian Mobile Phone if the Client is a minor: (N/A if it doesn't apply)

Question 40 of 61

Personal Information for Client(s) 13 & younger.  If you have more than one child younger than 13 who is listening to Inner Dynamics Coaching (IDC) sessions, put their information on a separate line.  Fill out a separate form for all children 14 & older.

 

#1  Child's Name, Age, Date Of Birth (mm/dd/yyyy)

#2 Child's Name, Age, Date Of Birth (mm/dd/yyyy)

 

Put N/A if this doesn't apply.

Question 41 of 61

Client's Name (14 & older, put N/A if the client is younger):

Question 42 of 61

Client's Age (14 & older, N/A if the client is 13 or younger):

Question 43 of 61

Client's Date of Birth (dd/mm/yyyy) (N/A if the client is 13 or younger):

Question 44 of 61

Client's Email (14 & older, N/A if the client is 13 or younger):

Question 45 of 61

Client's Mobile Phone (put N/A if the client is 13 or younger):

Question 46 of 61

Name(s) of Party Responsible for Payment:

Question 47 of 61

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

Question 48 of 61

Mobile Phone of Party Responsible for Payment:

2022 Personal Success Dynamics Coaching (PSDC) Membership Policies & Procedures

For Peggy Nazer Coaching

Question 50 of 61

Personal Success Dynamics Coaching (PSDC) Membership is for private use only.  PSDC membership is not a certification program for participants to become a coach, instructor, or energy psychology practitioner.  Participants are prohibited from teaching or sharing any information, training, coaching, or other content from the PSDC membership.

 

(Select all that apply)
A

I understand that my PSDC membership is for my private use only.

B

I understand that my participation in PSDC does not serve as a certification in any discipline.

C

I understand that any information I learn in PSDC is for my own consumption and not to be taught or shared with others.

Question 51 of 61

**Submitting all forms by all involved parties for Personal Success Dynamics Coaching (PSDC) is required before purchasing the membership subscription and must be completed; otherwise, access to the session portal is revoked.  

 

(Select all that apply)
A

I understand that the Personal Dynamics Coaching (PDC) Membership Intake Forms are required for enrollment and must be completed by all involved parties before purchasing PSDC membership. I understand clients 18 and older and the Party Responsible for Payment must submit these forms before purchasing PSDC membership.

Question 52 of 61

Intake Form Submission According to Age:

 

Having the proper forms in advance enables access to the PSDC membership portal.

 

All correct parties must submit all documents before purchasing the Session, or the system denies access to the membership portal.

 

Here are the requirements on who submits which forms:

 

  • Clients 18 years and older and are the Party Responsible for Payment must submit all forms.
  • Clients 18 years and older must submit all forms, even if they are NOT the Party Responsible for Payment.
    • If the client is 18 years and older but is NOT the Party Responsible for Payment, then the Party and the Client submit all forms.
  • Parent/Guardian/Party Responsible for Payment must submit all intake forms for children considered a dependent (single child age 24 or younger, or older child with special needs)
  • Parent/Guardian/Party Responsible for Payment must submit all intake forms for adult children whose service they are paying.  (ex. married child, 25 or older.)
    • Parent/Guardian submits "Personal Success Dynamics Coaching Intake Forms."
    • Adult child submits all forms.

 

(Select all that apply)
A

I understand the submission of forms by age procedure.

B

I understand that if I am the Party Responsible for Payment for services for my married child or my child 25 or older, I submit all forms.

C

I understand that all clients 18 years and older submit all forms regardless of whether they are the Party Responsible for Payment or not.

Question 53 of 61

Session Terms & Procedure:

 

Personal Success Dynamics Coaching Memberships are available to all who purchase; however, the offers are different dependent on membership in Success Dynamics Academy.

 

  • SDA members should register for "members only" Sessions
  • Non-SDA members must register for non-SDA Sessions

 

Non-SDA members who register using a "members only" offer will be denied access to the Session and must re-purchase the correct offer.  In addition, a minimum $10 processing fee will be charged. 

 

Personal Success Dynamics Coaching Sessions are delivered into an online membership portal so that clients may listen to and review sessions and lessons at their convenience.

 

Personal Success Dynamics Coaching Membership is offered per person.  Therefore, each person listening to PSDC sessions or training lessons should have purchased a membership subscription and submitted the proper forms.

 

EXCEPTION for Minor-Aged Siblings:  Minor-aged siblings may share a membership subscription rather than be paid for separately.  However, parents should appropriately document all children on the forms.

 

Clients have access to PSDC sessions and training lessons for as long as they are on subscription. 

 

 

 

Recording or downloading the session is not permitted.

 

You may download worksheets and surveys for your personal use; however, copying, sharing, or otherwise distributing the sessions or content is not permitted.

 

(Select all that apply)
A

I understand the importance of registering for the correct Personal Success Dynamics Coaching Membership, which depends on whether I am or am not a member of Success Dynamics Academy.

B

I understand that if I register for an "SDA members-only" Personal Success Dynamics Coaching Membership and I am not an SDA member, the system will revoke my access. I will have to re-purchase and request a refund, which will entail a minimum $10 booking fee.

C

I understand that the Personal Success Dynamics Coaching Membership is per person per session, and I will not share the session with those who have not paid for it.

D

I understand that minor children who are siblings can share a membership. All children need to be accounted for on the Personal Success Dynamics Coaching Intake Form. (Children 14-17 need separate forms.)

E

I understand and agree that I will NOT record or download the session.

Question 54 of 61

What to Expect:

 

Inner Dynamics Coaching (IDC) sessions combine coaching, training, and Energy Psychology (EP).

 

EP is a collection of mind-body approaches for understanding and improving human functioning.

 

EP focuses on the relationship between thoughts, emotions, sensations, behaviors, and known bioenergy systems (such as meridians and the biofield).

 

It is beneficial to feel comfortable and familiar with how sessions look before attending your first group session.

 

If you haven't done so already, read the answers on Peggy's FAQ page, so you have a working knowledge of what she does, how she does it, the materials you need on hand, and the options available to you.  That way, we get the most out of our time together.

 

Click to go to the FAQ page: https://www.peggynazer.com/faq-s *

 

(Select all that apply)
A

I have read the FAQ page and understand session procedures and what to expect.

B

I understand I will benefit from having printer paper and crayons on hand before the start of all sessions.

Question 55 of 61

Cancellation Policy:

 

Sometimes people are tempted to cancel their subscription.  Please be very conscious that the nature of these sessions can sometimes challenge you to follow through.  Often, the times you want to cancel are the very times you need to continue forward and remove the block in your way.

 

You may cancel any time before the next billing cycle within your PayPal account.

 

You may also email us with a cancellation request.  Please email at least a week before your next billing cycle to allow time for the cancellation request to process.  Send requests to:

 

 [email protected] 

 

  • There are no refunds on any current or prior month.  When you enroll, you have immediate access to several training lessons and at least 5 coaching sessions all with the accompanying worksheets, so you can begin training and coaching immediately.
  • If you cancel you lose access to the Personal Success Dynamics Coaching Library and any included bonuses.
  • If you choose to re-enroll, your membership will restart with the Foundation Training and beginning sessions, not pick up where you left.
  • If you need to cancel a subscription because you purchased an "SDA only" membership, you will receive a refund minus a $10 processing fee.

 

 

(Select all that apply)
A

I understand I can cancel my membership any time before the next billing cycle within my PayPal account.

B

I understand I can make a cancellation request via email but will need to give at least a week's notice before my next billing cycle to allow processing time and avoid another payment.

C

I understand I do not receive a refund after purchase, not for any current or prior month of my membership.

D

I understand that if I purchase an "SDA only" membership, I will need to cancel, re-purchase the correct membership, and request a refund. I will also be charged a $10 processing fee.

E

I understand that I cannot selectively cancel sessions while on a recurring subscription. Canceling a session will effectively cancel the subscription.

Question 56 of 61

Completed Intake Forms are required from Clients 18 years and older, Parents of Minor Clients, AND the Party Responsible for Payment of Services.

 

Be sure to submit separate forms where necessary so that all documents are received from all required parties; otherwise, the system denies portal access.

 

(Select all that apply)
A

I understand that these Forms must be submitted by clients 18 years and older, by parents of minor clients, AND by the party responsible for payment. Failure to fill out all fields and submit these forms by all parties involved before purchasing the PSDC membership will result in denied portal access.

Question 57 of 61

Another limitation of this form's platform is that there is no "back" button; however, after submitting this document, you will be able to see your results.  Please review all personal information to make sure it is correct and complete.  If you missed or misspelled anything, please correct it and resubmit.  Your missing or inaccurate information can result in your withdrawal from enrollment without a refund.

 

(Select all that apply)
A

I understand that all information on this form must be correct and complete.

B

I understand that missing or inaccurate information can result in my withdrawal from enrollment without a refund.

C

I understand that I can review my information on the forms after submitting them. I can resubmit corrected documents if necessary.

Question 58 of 61

You certify that you have read, understand, and agree to all the policies and procedures for Peggy Nazer Coaching.  Your submission of this form serves as your electronic signature.

 

(Select all that apply)
A

I certify I have read, understand, and agree to the Personal Success Dynamics Coaching Membership Policies and Procedures for Peggy Nazer Coaching. I understand that submitting this form serves as my electronic signature.

Question 59 of 61

Please state, using the exact phrases written in bold, the position that describes you best:

 

The Client - Party Responsible for Payment (You or your spouse pays for enrollment.)

 

The Client - Not Responsible for Payment (This answer typically applies when the client's enrollment is paid for by a parent/guardian. NOTE:  client's under 18 do not fill out this form.)

 

The Parent/Guardian - Party Responsible for Payment

 

Party Responsible for Payment - Not Guardian (This answer typically applies if another relative, a friend, or clergy is paying for the client's enrollment.)

 

After reading through the descriptions above, the position that describes me best is:

Question 60 of 61

Type your name as it would appear on a Signed Document.

After you have successfully completed these forms, you are ready to purchase.

Go to the tab where you accessed these forms' link.  Click the "purchase" button to complete your enrollment.

 

See you soon!

Confirm and Submit