POLICIES & DISCLOSURE STATEMENT

Your name

Your email

Your Age

Your Address

Cell Phone

Home Phone

Occupation

Marital Status

EMERGENCY CONTACT
Emergency Contact Name

Relationship

Phone Number

Date of First Appointment (if scheduled)

What are your goals for embodied coaching sessions?

How many sessions are you interested in?
Single sessionA few sessionsOngoing sessions (long-term)

EMBODIED MINDFULNESS COACHING:
Embodied Mindfulness Coaching is a two-way process between the guide and client; it is NOT psychotherapy, medical, legal or other advice. The guide is not here to ‘heal’ or ‘fix’ me, but more like hold the intention and clarity of an energetic space for me to explore. Starting with an assumption of wholeness and worthiness, the guide will assist me in processing my emotions and beliefs. Working only with what is on the surface in the moment, this process is both gentle and healing at the same time; no need to push or go digging deep. The length, depth, and benefits of this process depend largely upon my active participation, including a willingness to examine and take responsibility for my emotions and beliefs.

By signing below, I understand that Kristy Cronkrite is working with me as a mindfulness guide, not a licensed psychotherapist or medical professional. I understand the benefits and limitations of coaching. I understand that the time frame and outcome will largely depend upon my participation. I take full responsibility for my emotions and beliefs that may come up as a result of this work and hereby release Kristy Cronkrite Coaching from responsibility and liability of any discomfort that may occur as a result of participating in embodied mindfulness coaching.

MOVEMENT:
Sometimes embodied mindfulness sessions will include suggested physical movements as an opportunity for relaxation and relief of tension. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I understand that any injuries (past or present), and any illness or conditions (chronic or temporal) that I may have now or have had in the past can impact my mindful movement practice. I understand that mindful movement is not a substitute for medical attention, examination, diagnosis, or treatment and that physical activity is not recommended and is not safe under certain medical conditions.

By signing below, I assume responsibility to decide whether I am physically fit for participation in embodied mindfulness sessions. If I have any doubts as to my health or fitness at any time, I will consult a doctor before engaging in physical activity. I take full responsibility for my bodily limitations. I hereby release Kristy Cronkrite Coaching from responsibility and liability of any injury that may occur as a result of participating in sessions guided by Kristy Cronkrite.

COVID-19:
During all in-person classes & sessions held indoors, students and instructors are expected to practice “social distancing” and everyone is encouraged to wear face coverings at all times to reduce the risks of exposure to infectious disease including but not limited to COVID-19. Because COVID-19 is extremely contagious and is spread mainly from person-to-person contact, Kristy Cronkrite has put in place preventative measures to reduce the spread of COVID-19. However, Kristy Cronkrite cannot guarantee that those in attendance will not become infected with COVID-19.

By signing below, I acknowledge and understand that participation in in-person classes or sessions includes possible exposure to and illness from infectious diseases including but not limited to COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19.

CANCELLATION:
By signing below, I agree to let Kristy Cronkrite know about financial hardships up front before booking a session. I understand that alternative payment arrangements are available if agreed upon in advance. By checking below, I indicate my understanding that classes/sessions require a minimum 24-hour notice of cancellation to avoid being charged for the full session fee and agree to pay in full regardless of the outcome of our work together.

Signed by

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