Personal Success Dynamics Coaching Intake Forms
HERE IS A PREVIEW OF THE PERSONAL SUCCESS DYNAMICS COACHING INTAKE FORMS
- CONSENT FORMS
- POLICIES AND PROCEDURES AGREEMENT
Please read and make sure you agree before purchasing the Personal Success Dynamics Coaching Membership.
You must submit all forms before purchase to complete enrollment and registration.
Failure to submit Forms before purchase will revoke access to the membership portal.
**You will not receive a refund if access is revoked. Once you complete the forms, you will be granted access.**
PERSONAL SUCCESS DYNAMICS COACHING (PSDC) INTAKE FORMS
FORM SUBMISSION GUIDELINES
Each person listening to the coaching sessions or training lessons must have each of the following forms submitted:
- Consent Forms - Release Form & Hold Harmless Form
- PSDC Policies & Procedures Form
Families, or others listening together, should purchase a membership for each person and submit all forms for each person.
The following parties must submit these forms:
- 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.
- Completed forms are required from the PSDC Client and the Party Responsible for the Payment of Services. Submit separate forms if the adult Client and the Party Responsible for Payment are not the same person.
- If the Client is a minor-aged child and the Parent/Guardian is the Party Responsible for Payment, then they need only fill out one form.
- If the Client is a minor-aged child and the Parent/Guardian is not the Party Responsible, then the parent/guardian and the Party Responsible will each fill out the forms.
Minor-aged children do not fill out these forms. All forms are completed and submitted by adults 18 & older.
Please make sure all involved parties submit these forms.
Your Information (or your child's) is never shared or sold!
Correct contact information is vital. It is needed here primarily for legal purposes and communicating about sessions: questionnaires, content availability, and reminders.
- Consent Form Information
- Policies and Procedures Form Information
If you have any questions or concerns, please email me:
RELEASE FORM
for Personal Success Dynamics Coaching
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.
HOLD HARMLESS FORM
for Personal Success Dynamics Coaching
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.
PERSONAL SUCCESS DYNAMICS COACHING POLICIES & PROCEDURES AGREEMENT
for Peggy Nazer Coaching
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.
Private Use Only:
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.
Intake Form Submission According to Age & Payment Responsibility:
Submitting the proper forms in advance enables access to the PSDC membership portal.
These Parties must complete Intake Forms:
- Clients 18 years and older
- Parent/Guardian of Minor-aged Clients
- Party Responsible for Payment of Services.
All required parties must submit these documents before purchasing the membership, or the system denies access to the membership portal.
There are no refunds due to lost access because of missing or incomplete forms.
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 Responsible 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.)
- Adult child (18+) submits all forms, even if they are not the Party Responsible for Payment.
- Party Responsible for Payment submits forms even if they are not the Parent/Guardian.
- Minor-aged Clients do not submit these forms themselves.
Membership Terms & Procedure:
Personal Success Dynamics Coaching Memberships are available to all who purchase; however, the offers differ on Success Dynamics Academy membership.
SDA members should register for "SDA special offer" PSDC membership. Non-SDA members must register for regular PSDC membership.
Non-SDA members who register using the "SDA special offer" link will be denied access to the online portal and must re-purchase the correct offer. In addition, a minimum $10 processing fee will be charged.
Personal Success Dynamics Coaching Sessions and training lessons are delivered into an online membership portal so Clients can listen to and review sessions and lessons at their convenience.
Personal Success Dynamics Coaching Membership is an individual membership. 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 enroll and pay for each child separately. However, parents should appropriately document all children on the forms.
Note: When a child turns 18, they should enroll in their individual PSDC membership for Adults and submit the Intake Forms. If the Parent is going to be the Party Responsible for Payment, then they will re-submit the forms as Parent/Guardian - Party Responsible for the new adult client's membership.
Clients have access to PSDC sessions and training lessons for as long as they are on subscription.
** Recording or downloading the coaching sessions or training lessons is not permitted.
Download worksheets and surveys for personal use; however, copying, sharing, or otherwise distributing the sessions, lessons, or content is not permitted.
Cancellation Policy:
Sometimes Clients are tempted to cancel their subscription. Please be very conscious that the nature of these sessions can sometimes be challenging. Often, the times Clients want to cancel are the very times they need to continue forward and remove the block in their way.
Party Responsible for Payment may cancel any time before the next billing cycle within their PayPal account.
Party Responsible for Payment 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:
There are no refunds on any current or prior month. Upon enrollment, Clients have immediate access to several training lessons and at least 5 coaching sessions, all with the accompanying worksheets, so they can begin training and coaching immediately.
Clients lose access to the Personal Success Dynamics Coaching Library and any included bonuses if they cancel.
If a Client chooses to re-enroll, their membership will restart with the Foundation Training and beginning sessions, not pick up where they left.
If a Client needs to cancel a subscription because they purchased an "SDA special offer" membership, they will receive a refund minus a $10 processing fee.
Completed Intake Forms are required from:
- Clients 18 years and older
- Parent/Guardian of Minor-aged Clients
- 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.
Submission is Agreement:
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.
UPDATED: August 18, 2022
