Thank you for choosing Unknotting By Nyya! Please PRINT OUT ALL the following and fill it out COMPLETELY, and MAIL IT TO ME.
Couples: If you and your partner will both be working with me, you EACH need to print, fill out, and mail your own copy of the following to me.
Please remember to double-check that you have filled out and signed everything completely, and to mail this IMMEDIATELY, along with payment, as I will be forced to cancel your session if anything is missing or doesn't arrive before our scheduled time.
If you have any questions or problems, don't be shy- give me a quick call at 716-785-5057, or email me, and I'll be right with you.
Thank you!
Nyya
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CONTACT FORM
Full Legal Name (please print)_____________________________________ nickname?______________________
If I am scheduling for Couples Coaching, my partner is: _____________________________________
Over 18? Yes no
Mailing Address__________________________________________State________Zipcode________
Email Address______________________________________________________________________
Phone__(______)_________________________________________________________
• I prefer to be contacted by (circle any that apply) mail email phone call texting
I,(name)_____________________________, hereby grant permission for Unknotting by Nyya to contact me for scheduling and check-up purposes. I can end any further contact simply by saying so, emailing or writing, and I understand that my info will NEVER be sold, traded, etc to other businesses. My contact information is completely confidential.
Signed,_______________________________ date________________
Allergic to, or afraid of, cats or dogs? Yes no
Are you unable to use stairs or leave the house for any reason other than childcare? (I will accommodate you!)
Would you prefer an in-office or phone session, or both?
If you would like phone sessions, you must agree to the following: I have chosen phone sessions and understand that all phone charges are my responsibility. I have an adequate phone plan to cover all charges.
Signed:________________________________date____________________
How did you hear about Unknotting? Were you referred by anyone? Do you have a gift certificate?
About how many times have you used Unknotting before, or is this your first time?_________________________
BY SIGNING BELOW YOU AGREE TO ALL TERMS BELOW AND RECOGNIZE THIS AS A LEGAL AND BINDING AGREEMENT.
I, the undersigned…
Am of age 18 or over;
Know and agree that the Unknotting problem-solving and life coaching methods are purely the copyrighted creation and possession of Crystal Nyya Hites, and I will not plagiarize them in either whole or part and in either letter or spirit;
Recognize that my “Unknotting sessions” are NOT to replace my own good judgment;
Recognize that my “Unknotting sessions” are NOT conducted by a trained or licensed mental health professional, and is not meant to treat or cure any mental or physical illness;
Recognize that my “Unknotting sessions” are NOT meant to prevent, assess, counsel, or otherwise handle suicide, homicide, or any person feeling suicidal or homocidal;
Recognize that my “Unknotting sessions” are NOT meant to handle any emergency situation or situation involving child abuse, domestic or other violence, self-injury, drug, alcohol, or other illegal or dangerous situations;
Recognize that my "Unknotting sessions" are NOT meant or able to provide any legal adivce, medical advice, or any help obtaining social services;
Recognize that my “Unknotting sessions” are NOT intended to solve or bring about a final resolution to any problem, but only to clarify my options and enhance my own decision making process.
INSTEAD…
My “Unknotting sessions” are meant to help me sort through the issue(s) I present and arrive at their resolutions myself. They are for guidance and assistance in the thinking process, not for advice as to “what I have to do” about solving a problem.
Therefore…
All decisions and choices I make based in whole or in part of this “guidance meeting” are solely my own and in my own free will, and I hold Crystal “Nyya” Hites (and all other participating parties) free of any liability regarding to these transactions, including anything I may construe as legal or medical advice.
I recognize that if I am feeling suicidal or am in need of professional psychological therapy or evaluation it is MY RESPONSIBILITY ALONE to locate and use these professional services; that Crystal “Nyya” Hites is not legally responsible for helping me with such (even if by a choice of goodwill she undertakes an attempt at such); and I will not hold her liable in the event that she fails to provide such services or refer me to such services, as this is not her intent nor obligation.
I do not expect Crystal “Nyya” Hites, under any circumstances, to provide me with professional psychological or medical assistance, notify authorities of my need of such, or have me admitted to a hospital for such; and therefore free her (and all other parties) of all responsibility and liability for not doing such.
HOWEVER…
In the event that my actions, behaviors, or words cause her or another party to believe that I am in serious need of immediate psychological or other help, I recognize (though it is not their responsibility to do so, and cannot be expected to do so or held liable for not doing so) I completely release Crystal “Nyya” Hites and all other parties of any and all liability for calling 911 or other emergency services to obtain immediate psychological or medical care for me, including any financial liability. It is my responsibility to pay for all charges should an emergency call to 911 be made.
Signed:_______________________________ date______________
IN ADDITION:
I agree not to hold Crystal “Nyya” Hites and accompanying parties liable in any way for either acting, or failure to act, on behalf of another mentioned by me in a “guidance meeting” who may or may not be in need of professional medical, psychological, or other assistance;
I agree not to hold Crystal “Nyya” Hites and accompanying parties liable in any way for reporting, or failing to report, any child abuse, domestic abuse, drug or alcohol or illegal or dangerous other activity or involvement, to authorities.
I agree that by agreeing to an in-office session, the home-office premises is by all means safe, that stairs cause no danger or difficulty for me , and that I waive all liability to Crystal “Nyya” Hites for ANY injury or accident, such as slip-and-fall. If ever I feel that the premises is unsafe, by way of ice, obstacle, wet floor, poor lighting or nay other hazard, I know that I have the right and option to refuse in-office sessions and replace them instead with over-the-phone or alternate location sessions without penalty; but it is MY responsibility to insist on a phone or alternate location session. If I am in any way disabled, it is my responsibility inform Crystal Nyya Hites and insist on an option that works for me without jeopardizing my health or safety; and by agreeing to any session, I agree that she has accommodated me properly. I agree that if I participate in an in-office session, I waive all rights to sue or demand any compensation for any injury or accident that may occur on the property both indoors and outdoors, for any reason whatsoever.
IN OTHER WORDS:
These guidance meeting are a non-professional “goodwill” service, limited in scope and ability, and are not meant to handle emergency situations, or give legal or medical advise. Any thing done therein by Crystal “Nyya” Hites and accompanying parties is done out of their best, non-professional judgment, and is not to be held accountable or liable in any way for “bad advice” or the improper handling of an emergency situation or mental health condition involving me, any person present at the guidance meeting, or another mentioned by me who is not present. If I tell them something, they may or may not call emergency services or law authorities, and I will not hold them liable either way.
I FULLY UNDERSTAND AND AGREE TO ALL THE ABOVE, AND AM AT LEAST 18 AND IN SOUND MIND TO THINK AND ACT FOR MYSELF.
Signed:_______________________________ date______________
Satisfaction Guarantee:If you do not feel that Unknotting was helpful, simply say so, and you have no obligation to pay. All recourse against me is limited to full amount of money back for that day’s session only. There is no refund for past sessions in a series or package of sessions, only each session individually. If you arrive, or call, thirty or more minutes late for your session, your refund is limited to half instead of full, as you cannot get a full-quality session in a rushed, half-time session.
There are NO extra fees or things to purchase, and no on-going commitment.
Unknotting is not covered by insurance.
You will be held responsible for all bounced check fees.
I have seen these terms and prices and agree to them in whole.
Signed_________________________________date_______________________________
General Rules:
You agree to seek professional help, on your own, if needed.
I cannot do immediate/ emergency sessions. When you call, we’ll make an appointment as soon as is convenient for both of us. If you need help sooner, this is obviously an emergency and you need to contact the appropriate authority yourself.
I can’t help you if you don’t want to be helped. Are you really ready to solve your problem? An open mind and willingness to listen and make changes make all the difference in the world! Or, do we need to discover why you keep repeating the same issues in your life first? If venting is all you want and you say so, that is fine, but my time holds the same monetary value.
Couple’s meetings. In regards to relationship worries, I generally start with both of you present at once. I will work both of you, and then ask one person to leave while I speak with the other… and then vice-versa. Then I will work with you both simultaneously. This is completely case by case, but in the earlier stages of resolution, having both partners present for the entire meeting might be nothing more than a shouting match! Therefore, please bring your cell phone and be prepared with a plan to go shopping, grab lunch, or some other half-hour long activity while I work with each of you individually if we meet in person.
I cannot work with anyone under the age of 18.
Please, NO eating while in session over the phone or in person with me.
Parents, please do not bring your children with you for in-person sessions; and have time and space apart for them for over the phone sessions. You will need to be able to focus and speak freely. I may cancel our meeting if you cannot find a sitter or are continually interrupted or distracted; or if there is overwhelming background noise.
I reserve the right to cancel meetings or meeting with any client for any reason, but will issue a full refund for all FUTURE sessions in a package in this instance.
I only accept cases I am confident I can assist in, for your sake and mine. Please do not be offended if your particular situation is not accepted.
If you need to cancel a meeting, PLEASE call ASAP! It is just polite and frees me to help others!
I am completely comfortable with and non-judgmental towards all faiths, races, sexual orientations, genders, etc. I do not discriminate against anyone. Please feel free to be yourself and if you need to talk about religious issues, issues of orientation, etc., I will keep these considerations in mind while helping you work through your problem(s), so that any ideas we come up with will be tailored personally to you.
I cannot give financial, legal, or medical advice, and navigating social services is up to you.
I am not a licensed mental health professional and I cannot diagnose, treat, or cure any illness, mental or physical, and I cannot prescribe medications.
I can’t make phone calls to your ex on your behalf, find a good counselor for you, research spiritual paths that suit you, etc., although I may in good faith do a little of this for you if I can. I can help you figure out what needs to be done and how to do it. I cannot do it for you. If I opt to do more than this, it is on a case-by-case agreement and we will need to work out special terms. If you need this sort of special help, please say so!
Coaching is a partnership. We both have responsibilities to each other if coaching is to be successful. Please, tell me what you expect from me, what you need from me, what I can best do to help, and what won't help, and what will be of true value to you! Likewise, you are responsible for doing what you contract to do, for taking action, and for coming to our sessions prepared with whatever homework we agree on. A better life requires work and maybe some "stretching" into things that are new or a little scary- but if you'll do it, I'll help you through it, and success will follow!
I cannot cover your marital issues, problem with your best friend, and need to work out your kid’s birthday party with his step mom all in one meeting! There’s a difference between a problem that has a couple aspects to it and a couple different problems. I can cover a multi-aspect issue in one meeting; but different problems will require different sessions and time of their own.
No smoking indoors during workshops or sessions at the office, please.
It is YOUR responsibility to tell me if any special accommodations need to be made for you. Please let me know if you have difficulty with stairs, allergies or fears of cats and dogs, or anything else pertinent.
If you want me ONLY TO LISTEN while you vent for an hour, please say so, and that’s what we’ll do. But please note, my time holds the same monetary value and the same fees apply.
It is YOUR responsibility as the client to call me or arrive at the scheduled time. I will wait about 15minutes into your appointment before trying to call you. If we connect 20 or more minutes late, for either a phone or in-person session, you are eligible for only 1/2 of the full refund amount back if you are dissatisfied, since a full value session can't be had in a rushed part-time session.
Three strikes against a client (no-call no-show, same-day cancel, bounced check, distractions over phone such as kids or video games) will be considered grounds to terminate our coaching relationship.
You are responsible for all bounced/bad check costs, and will not be able to schedule for further sessions until the bad payment and associated costs are made up. You may not be allowed to pay by check in the future if you bounce a check. Current bad check fee is $20.00 plus the amount of the bad check.
When I say that a session runs a certain time for a certain amount, I mean that the session will cost you that amount whether we complete before your scheduled time is up; but YOU decided when the session is complete and are completely entitled to the full length of time- I will never rush you through. A fifteen minute break is included in the price for all sessions over 1 hour long.
There are NO discounts for finishing or having to leave or end the session early.
If a session runs over-time or cannot be finished before our time slot ends, we will schedule another session. That session will be the regular full price, unless it is by my error that our session started late and could not be completed. In that event, you will be credited a pro-rated amount of time.
I have seen these terms and agree to them in whole.
Signed, ______________________________________date_____________________________
Unknotting Method and Tools Copyright 2005; All Website Contents Copyright 2009-2010 Crystal Nyya Hites. May not be used or copied without explicit written permission.