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Last
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Phone
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Client Type
(Required)
New Client
Current Client
Choose Service Established
(Required)
Functional Health Coaching
Holistic Counseling
Integration Therapy
Choose Your Functional Health Coach
(Required)
Aleks
Choose Your Holistic Counseler
(Required)
Aleks
Sara
Choose Your Integration Therapist
(Required)
Sara
Terms And Agreements
Registration cannot be completed until you have read and acknowledged this form by clicking the below. PLEASE READ THE FOLLOWING CAREFULLY:
I understand that the practitioners, and all representatives of PRIMAL FUSION, do not diagnose, treat, prescribe or cure disease.
(Required)
I UNDERSTAND
I understand that the practitioners, and all representatives of PRIMAL FUSION, do not diagnose, treat, prescribe or cure disease.
I understand that each representative of Primal Fusion has completed all necessary certifying programs, taken numerous seminars, and courses in diet and lifestyle counseling, holistic nutrition, integrative kinesiology, and sports & exercise training. I understand that they are certified to coach, train, consult, and provide counseling on cognitively associated behaviors centered in lifestyle habits with the knowledge to provide professional advice about fitness and wellness, but is not a licensed healthcare provider, and is unable to prescribe medications and/or diagnose disease.
(Required)
I understand that each representative of Primal Fusion has completed all necessary certifying programs, taken numerous seminars, and courses in diet and lifestyle counseling, holistic nutrition, integrative kinesiology, and sports & exercise training. I understand that they are certified to coach, train, consult, and provide counseling on cognitively associated behaviors centered in lifestyle habits with the knowledge to provide professional advice about fitness and wellness, but is not a licensed healthcare provider, and is unable to prescribe medications and/or diagnose disease.
I UNDERSTAND
I understand that representatives of Primal Fusion are qualified to implement nutritional, spiritual, emotional and physical therapies to enhance my well-being, comfort, and life goals. I understand that they are not medical doctors, and are not legally permitted to diagnose or treat “disease”, but are qualified and legally endorsed to provide me with holistic advice with the intent to build and maintain health and wellness, provide exercise training and coaching, massage therapy and Neurosomatic Therapies, cognitive-behavioral exercises and mental, emotional and spiritual life coaching. I acknowledge and understand that, in some uncertain terms, they may refer me to a functional or medical doctor, psychologist and or other licensed experts in the field of wellness, should they determine the need to and that it is my choice to accept any or all referrals provided.
(Required)
I understand that representatives of Primal Fusion are qualified to implement nutritional, spiritual, emotional and physical therapies to enhance my well-being, comfort, and life goals. I understand that they are not medical doctors, and are not legally permitted to diagnose or treat “disease”, but are qualified and legally endorsed to provide me with holistic advice with the intent to build and maintain health and wellness, provide exercise training and coaching, massage therapy and Neurosomatic Therapies, cognitive-behavioral exercises and mental, emotional and spiritual life coaching. I acknowledge and understand that, in some uncertain terms, they may refer me to a functional or medical doctor, psychologist and or other licensed experts in the field of wellness, should they determine the need to and that it is my choice to accept any or all referrals provided.
I UNDERSTAND
Program Factors Registration Intake
Time
Consider your time availabilities and limitations.
How much time can you give to appointments each month?
(Required)
1 Hour
2 Hours
3+ Hours
How much time can you commit to doing the work in your program, or the work I assign to you?
(Required)
30 minutes per day
1 hour per day
2 hours or more per day
1-2 hours per week
2-4 hours per week
How much time do you need to absorb, integrate and synthesize the revelations and insights you will experience in that work?
(Required)
1 Week
2 Weeks
3 Weeks
How much time do you need to absorb, integrate and synthesize the revelations and insights you will experience in that work?
(Required)
1 Week
2 Weeks
3 Weeks
Energy
How much energy do you have to perform the mental/emotional work? (on a sale 1-10, 10 being the highest)
(Required)
Please enter a number from
1
to
10
.
How much energy do you have to perform the physical work? (on a scale 1-10, 10 being the highest)
(Required)
Please enter a number from
1
to
10
.
How much energy do you have to perform the Spiritual (or development/expansion of conscious awareness) work? (on a sale 1-10, 10 being the highest)
(Required)
Please enter a number from
1
to
10
.
RESOURCES
For exercise programs, or in cases where I believe movement/exercise therapy is needed, what equipment do you have at home, school, office or other gym memberships? Describe & list exercise equipment and space:
(Required)
Do you have other practitioners/physicians or providers that you work with or have access to that can/do/would support your mental/emotional and physical health needs (FDNs, MDs, Chiropractors, massage therapy, LPCs etc? If so, please list below the *types* of providers you are currently working with, and/or have worked with within the past 3 months:
(Required)
What other resources or tools do you have available to you and/or are more open to including?
(Required)
Check all that apply
Cryotherapy
Sauna
Massage
Fitness Memberships
Meal Services
Access to clean, organic, whole foods
Kindle and/or audiobook subscriptions
Netflix, Gaia subscriptions
Other
Enter Your Other Resources
(Required)
Who in your life can/ will support you in the journey you are going on?
(Required)
Who will accept you, even as you change?
(Required)
Who will love, support and accept you as you begin to make changes in your life?
(Required)
BUDGET
What is a safe monthly budget that will not cause stress for you to include or add things such as food, supplements, recommended equipment, therapies, books and/or other tools for learning, in addition to our work together?:
(Required)
WILLINGNESS
How willing are you to commit to the program I design for you, and/or the therapeutic guidance I provide if we can meet all of the above factors? (on a sale 1-10, 10 being the highest)
(Required)
Please enter a number from
1
to
10
.
How willing are you to communicate and/or express your feelings, wants, needs and/or arising challenges to me throughout the duration of your program? (on a sale 1-10, 10 being the highest)
(Required)
Please enter a number from
1
to
10
.
CONSENT
I hereby consent to participate in: (check all that apply):
(Required)
A health program that may include corrective stretching, corrective exercises, resistance training, and/or postural exercises.
A nutrition and holistic lifestyle program that may include dietary recommendations, detoxification, and stress reduction protocols and methods.
Alternative therapies and protocols that may include, sound, art, movement, mediation, and/or herbal treatment. These therapies may also include an investigation of my core beliefs and thinking.
Select All
PERSONAL RECORD OF INFORMATION
Name
First
Last
Date of Brith
(Required)
MM slash DD slash YYYY
Age
(Required)
Please enter a number from
1
to
110
.
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
DISCLOSURE & LIABILITY AGREEMENT
I understand that information I possess about my health status and/or previous experiences of unusual feelings with physical effort and/or injury may affect the safety and value of my therapy session. I understand that I may feel discomfort and pain during this session and that is to be expected during muscle and tissue release performed by my therapist. I acknowledge that my prompt reporting of unusual feelings during the session itself is extremely important and that I am responsible for fully disclosing such information whether or not requested by the therapist. I understand the helpfulness of reporting any pain or discomfort by levels 1 to 10, and that discomfort is to be expected before relief.
(Required)
I understand that information I possess about my health status and/or previous experiences of unusual feelings with physical effort and/or injury may affect the safety and value of my therapy session. I understand that I may feel discomfort and pain during this session and that is to be expected during muscle and tissue release performed by my therapist. I acknowledge that my prompt reporting of unusual feelings during the session itself is extremely important and that I am responsible for fully disclosing such information whether or not requested by the therapist. I understand the helpfulness of reporting any pain or discomfort by levels 1 to 10, and that discomfort is to be expected before relief.
I UNDERSTAND
I fully understand that if I miss or cancel a scheduled appointment without 24-hours notice, I will be charged $500.00. However, the balance of the deposit is transferable to an appointment at a later date, provided the next scheduled date falls within one year from the initially scheduled appointment.
(Required)
I fully understand that if I miss or cancel a scheduled appointment without 24-hours notice, I will be charged $500.00. However, the balance of the deposit is transferable to an appointment at a later date, provided the next scheduled date falls within one year from the initially scheduled appointment.
I UNDERSTAND
I acknowledge that appointment times are reserved and that cancellations must be made 48 hours in advance in consideration of the coach’s planning, as well as other clients on a waiting list for specific time slots. Cancellations must be made by calling OR TEXTING: 512. 468. 1036 (voicemail/text will record date/time). I understand that I will not receive a refund for missed appointments. It is my responsibility to attend my personal training appointments when they are scheduled.
(Required)
I acknowledge that appointment times are reserved and that cancellations must be made 48 hours in advance in consideration of the coach’s planning, as well as other clients on a waiting list for specific time slots. Cancellations must be made by calling OR TEXTING: 512. 468. 1036 (voicemail/text will record date/time). I understand that I will not receive a refund for missed appointments. It is my responsibility to attend my personal training appointments when they are scheduled.
I UNDERSTAND
RESPONSIBILITIES
I understand that information I possess about my health status and/or previous experiences of unusual feelings with physical effort and/or injury may affect the safety and value of my therapy session. I understand that I may feel discomfort and pain during this session and that is to be expected during muscle and tissue release performed by my therapist. I acknowledge that my prompt reporting of unusual feelings during the session itself is extremely important and that I am responsible for fully disclosing such information whether or not requested by the therapist. I understand the helpfulness of reporting any pain or discomfort by levels 1 to 10, and that discomfort is to be expected before relief.
(Required)
I Understand
I understand that information I possess about my health status and/or previous experiences of unusual feelings with physical effort and/or injury may affect the safety and value of my therapy session. I understand that I may feel discomfort and pain during this session and that is to be expected during muscle and tissue release performed by my therapist. I acknowledge that my prompt reporting of unusual feelings during the session itself is extremely important and that I am responsible for fully disclosing such information whether or not requested by the therapist. I understand the helpfulness of reporting any pain or discomfort by levels 1 to 10, and that discomfort is to be expected before relief.
I fully understand that if I miss or cancel a scheduled appointment without 24-hours notice, I will be charged $500.00. However, the balance of the deposit is transferable to an appointment at a later date, provided the next scheduled date falls within one year from the initially scheduled appointment.
(Required)
I fully understand that if I miss or cancel a scheduled appointment without 24-hours notice, I will be charged $500.00. However, the balance of the deposit is transferable to an appointment at a later date, provided the next scheduled date falls within one year from the initially scheduled appointment.
I Understand
I acknowledge that appointment times are reserved and that cancellations must be made 48 hours in advance in consideration of the coach’s planning, as well as other clients on a waiting list for specific time slots. Cancellations must be made by calling OR TEXTING: 512. 468. 1036 (voicemail/text will record date/time). I understand that I will not receive a refund for missed appointments. It is my responsibility to attend my personal training appointments when they are scheduled.
(Required)
I acknowledge that appointment times are reserved and that cancellations must be made 48 hours in advance in consideration of the coach’s planning, as well as other clients on a waiting list for specific time slots. Cancellations must be made by calling OR TEXTING: 512. 468. 1036 (voicemail/text will record date/time). I understand that I will not receive a refund for missed appointments. It is my responsibility to attend my personal training appointments when they are scheduled.
I Understand
BENEFITS TO BE EXPECTED
I understand that results obtained from the session vary from person to person and from each visit. I understand that I may feel immediate relief, mobility, flexibility, and overall wellness but that it may also take a few sessions to see improvements depending on the variability and severity of my pain and injuries. I understand that NST can cause symptoms to get worse before they improve.
(Required)
I understand that results obtained from the session vary from person to person and from each visit. I understand that I may feel immediate relief, mobility, flexibility, and overall wellness but that it may also take a few sessions to see improvements depending on the variability and severity of my pain and injuries. I understand that NST can cause symptoms to get worse before they improve.
I Understand
I understand that nutritional advice is not intended to replace the advice of a medical doctor. I understand that no claim is made as to the certain efficacy of any nutritional protocols.
(Required)
I understand that nutritional advice is not intended to replace the advice of a medical doctor. I understand that no claim is made as to the certain efficacy of any nutritional protocols.
I Understand
I acknowledge and understand that some therapies may also include an investigation of my core-beliefs and thinking and that alternative therapies are not intended to replace the advice of a medical doctor. I understand that no claim is made as to the certain efficacy of any alternative therapy protocols.
(Required)
I acknowledge and understand that some therapies may also include an investigation of my core-beliefs and thinking and that alternative therapies are not intended to replace the advice of a medical doctor. I understand that no claim is made as to the certain efficacy of any alternative therapy protocols.
I Understand
PRIVACY & FREEDOM OF CONSENT
My permission to participate in this program, including but not limited to physical assessments, exercises, neurosomatic therapy, counseling, and other therapies by me is voluntary. I understand that I am free to stop at any point, if I desire.
(Required)
My permission to participate in this program, including but not limited to physical assessments, exercises, neurosomatic therapy, counseling, and other therapies by me is voluntary. I understand that I am free to stop at any point, if I desire.
I Understand
I understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injury, spinal injuries, abnormal blood pressure responses, and in rare instances, heart attack or death. Every effort will be made to minimize these risks.
(Required)
I understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injury, spinal injuries, abnormal blood pressure responses, and in rare instances, heart attack or death. Every effort will be made to minimize these risks.
I Understand
Any information that is obtained from me regarding my medical history, fitness level, and progress will be treated as privileged and confidential and will not be released or revealed to any person other than my therapist without my expressed written consent.
(Required)
Any information that is obtained from me regarding my medical history, fitness level, and progress will be treated as privileged and confidential and will not be released or revealed to any person other than my therapist without my expressed written consent.
I Understand
EXPLANATION OF THE EVALUATION
I understand that sessions will run approximately one to four hours unless otherwise stated. I acknowledge that a delay to a scheduled session cannot change the session status to anything else except a whole session unless otherwise stated by my provider at that time.
(Required)
I understand that sessions will run approximately one to four hours unless otherwise stated. I acknowledge that a delay to a scheduled session cannot change the session status to anything else except a whole session unless otherwise stated by my provider at that time.
I Understand
I understand that I will perform an exercise and/or movement test, and may be asked questions about my health and physical well being during my initial consultation. I understand that I may stop whenever I wish because of feelings of fatigue or any other discomfort.
(Required)
I understand that I will perform an exercise and/or movement test, and may be asked questions about my health and physical well being during my initial consultation. I understand that I may stop whenever I wish because of feelings of fatigue or any other discomfort.
I Understand
I fully understand that all suggested health, rehabilitation, corrective, strength or performance programs are designed with my health and wellbeing and with my utmost safety in mind. In the event that I may injure myself as a result of my participation in this program, I hereby release, discharge, and waive any and all responsibility of Aleks Rybchinskiy, Sara Gustafson or agents and employees of Primal Fusion Holistic Health & Performance and associated companies and agencies now or in the future, including but not limited to heart attacks, muscle strains, sprains, pulls, tears, broken bones, shin splints, knee, back, or foot injuries and any other illness or injury, however caused, occurring during or after my participation in any of the above programs.
(Required)
I fully understand that all suggested health, rehabilitation, corrective, strength or performance programs are designed with my health and wellbeing and with my utmost safety in mind. In the event that I may injure myself as a result of my participation in this program, I hereby release, discharge, and waive any and all responsibility of Aleks Rybchinskiy, Sara Gustafson or agents and employees of Primal Fusion Holistic Health & Performance and associated companies and agencies now or in the future, including but not limited to heart attacks, muscle strains, sprains, pulls, tears, broken bones, shin splints, knee, back, or foot injuries and any other illness or injury, however caused, occurring during or after my participation in any of the above programs.
I Understand
EXPLANATION OF BILLABLE HOURS
I understand that billable hours are also applied to the work performed and executed by my provider(s) in between scheduled appointments including, but not limited to evaluation and review of my intake forms, due diligence, research and case planning, program development and design, and/or remote support. Practitioner case work requires focused due diligence on the client individually, and outside of scheduled appointments. Assessments, reports, assignments, guidance and continued integration work are necessary to every successful outcome, and these areas of practice outside of my one-on-one appointments are used to spend time on my goals, needs and challenges.
(Required)
I understand that billable hours are also applied to the work performed and executed by my provider(s) in between scheduled appointments including, but not limited to evaluation and review of my intake forms, due diligence, research and case planning, program development and design, and/or remote support. Practitioner case work requires focused due diligence on the client individually, and outside of scheduled appointments. Assessments, reports, assignments, guidance and continued integration work are necessary to every successful outcome, and these areas of practice outside of my one-on-one appointments are used to spend time on my goals, needs and challenges.
I Understand
I acknowledge and understand that this time spent researching, developing and integrating the best solutions and guidance for me may vary dependent upon my needs and/or requests, and that upon my request, I may receive a full disclosure of all time billable or used from my credits in increments of 30 minutes (0.50) with added notes to allow myself absolute visibility.
(Required)
I acknowledge and understand that this time spent researching, developing and integrating the best solutions and guidance for me may vary dependent upon my needs and/or requests, and that upon my request, I may receive a full disclosure of all time billable or used from my credits in increments of 30 minutes (0.50) with added notes to allow myself absolute visibility.
I Understand and Agree
PAYMENT TERMS AND AGREEMENT
I agree to terms of payment for my chosen program which includes the initial deposit or service fee, and all invoices paid in advance to continuing phases of program levels set out for me.
(Required)
I agree to terms of payment for my chosen program which includes the initial deposit or service fee, and all invoices paid in advance to continuing phases of program levels set out for me.
I Agree
I agree and understand that all hours of coaching and therapies are billable at the hourly rate and cancellations after the 48 hour window are not automatically redeemed as credit and this is to the discretion of my provider.
(Required)
I agree and understand that all hours of coaching and therapies are billable at the hourly rate and cancellations after the 48 hour window are not automatically redeemed as credit and this is to the discretion of my provider.
I Agree
I understand this money is not refundable and all requests are made to and considered by the discretion of the practitioner. I understand this contract and the terms it presents is for the purchase of sessions, billable hours, and any other purchase of services in the future. I acknowledge that this specific contract, and agreement is continuously valid indefinitely.
(Required)
I understand this money is not refundable and all requests are made to and considered by the discretion of the practitioner. I understand this contract and the terms it presents is for the purchase of sessions, billable hours, and any other purchase of services in the future. I acknowledge that this specific contract, and agreement is continuously valid indefinitely.
I Understand
I understand that I will be charged for the session(s) missed. No refund will be granted for sessions that have not been completed. I understand Austin Primal Fitness & Nutrition, LLC (DBA Primal Fusion) has the right and the authority to terminate the program at any time, with no refund, if I do not follow the program or fail to conduct myself in an appropriate manner.
(Required)
I understand that I will be charged for the session(s) missed. No refund will be granted for sessions that have not been completed. I understand Austin Primal Fitness & Nutrition, LLC (DBA Primal Fusion) has the right and the authority to terminate the program at any time, with no refund, if I do not follow the program or fail to conduct myself in an appropriate manner.
I Understand
Signature and Date
Typed Name
(Required)
First
Last
Today's Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
Payment Options
Choose Your The Number of Hours You Would Like to Purchase
(Required)
6 Hours Total
10 Hours Total
20 Hours Total
6 Hour Payment Options
(Required)
$2,820 Today and save 6% off the Full price 0f $3,000
$1,500 Today, then a 2nd payment of $1,500 in 30 Days (2 payments total)
10 Hour Payment Options
(Required)
$4,600 Today and save 8% off the Full Price of $5000
$1,667 Today, then 2 more payments of $1,667 charged every 30 days (3 payments total)
20 Hour Payment Options
(Required)
$9,000 Today and save 10% off the Full Price of $10,000
$2,000 Today, then 4 more payments of $2,000 charged every 30 days (5 payments total)
$3,333 Today, then 2 more payments of $3,333 charged every 30 days (3 payments total)
Submit the form to go to the payment page.