Thank you for choosing Jenifer Shapiro and The Empowerment Centre, LLC.

Patient Information

If you are completing this form for your child, please check here.  By doing so you are stating you are a legal guardian of this child.  Please then fill out the form for your child. *
If you are completing this form for your pet/ an animal, please check here.  By doing so you are stating you are a legal guardian of this animal.  Please then fill out the form for your pet/ animal. *
Is this your first time working with Jenifer? *
Would you like to receive our monthly informational newsletter (sample here)? You can opt-out anytime with one-click. *
Check the areas of Jenifer's work you are interested in. *
Please check all areas of interest and/or concern below. *
 
Please check any physical ailments you have now or have had (please explain further below, thank you). *
 
Everyone's path to healing is unique and everyone's pace is different. ┬áPlease choose what seems like your way: *
 

Authorization, Indemnity and Cancellation Policy

Authorization for Work and Explanation of Service 

I understand that my work with Jenifer Shapiro is not a replacement for allopathic medical advice and take full responsibility for ensuring that I and/or my child and/or my pet receive proper medical attention when needed.  I understand that the success of the session(s) depends in part on the client's willingness, ability and desire to take the actions needed to heal, empower, grow and manifest.  I recognize that holistic practices can be important tools in this process.  I realize the results of the session(s) may vary and that Jenifer Shapiro cannot guarantee nor determine the results of the therapy prior to or after the session(s). 

I am aware as well that Jenifer Shapiro will perform her work to the best of her ability in a professional manner in order to provide every avenue for success in the treatment. I take full responsibility for requesting to work with Jenifer Shapiro and I state that all information that I provide to Jenifer Shapiro is completely true to the best of my knowledge.  I state from fact that I have not been advised by a medical professional not to engage in alternative treatments.

I fully authorize Jenifer Shapiro to perform coaching, homeopathy, nutritonal consulting, NLP, IRT, hypnotherapy and/or holistically-oriented techniques with me and/or my child and/or my pet for the purpose of enhancing my life, physical/ emotional/ spiritual healing, changing unwanted habits, releasing stress, manifesting a new career or business, or for other purposes that I may request.

I recognize that I have other choices in seeking assistance, and that at this time I have chosen from sound mind and body to work with Jenifer Shapiro.  I authorize Jenifer Shapiro to perform holistically-oriented treatments/ work as mentioned above with me and will take responsibility to discuss with Jenifer Shapiro any techniques that I have concerns about or are uncomfortable with prior to treatment.  I also recognize that Jenifer may choose not to use certain techniques if she feels they may not create a beneficial effect for treatment.

I, for myself, for my heirs, personal representatives or assigns, do hereby waive, discharge, and covenant not to sue Jenifer Shapiro and do hereby release Jenifer Shapiro from any liability and all claims resulting in personal injury, accidents or illnesses (including death), and property loss, regardless of fault, arising from, but not limited to, our work together and/or her work with my children and/or my pet(s) whom I may choose to bring to work with her willingly.

Understanding Payment Policies

In an effort to offer optimal care, I require prepayment of all services. 

First sessions are to be prepaid in full within 2 days of booking.  After a first session, subsquent sessions require prepayment at least 24 hours prior to session time.  

All clients are offered instructions on how to prepay online and if they prefer, and there is adequate time before the session, prepayment by cash or check is offered as well.

Should a client need to pay at an in-person session, please contact Jenifer Shapiro to discuss options.

Please see the following for Cancellation policies.

Understanding of Cancellation Policy 

Note:  This cancellation policy is in place to ensure that I am able to consistently meet the needs of all of my clients.  Please do not ask for exceptions unless in true emergencies (we are all human and I do my best to work with you on emergency situations).  I go above and beyond to meet the needs of my clients and cannot continue to do so if I do not uphold my policies.  Thank you for respecting this. 

2 business days are required for any cancellations/ rescheduling of first sessions.  All changes made with 2 business days or less to appointments must be made via both email at js@theempowermentcentre.com and telephone to 610-213-1010. 

1 business day notice is required for any and all cancellations/rescheduling after a first session.  This means by 9am PST Friday for Monday morning sessions.  Cancellations/rescheduling with less than 1 business day notice will incur the full fee of the session unless session time can be filled by another client which we will do our best to do.    If the space can be filled by another client, a $75 late cancellation fee will be required in lieu of the full session fee for the first time only.  For clients who cancel with less than 1 business day notice, prepayment may be required for future sessions.

***Our cancellation policies are online as well and any updates can be found there at anytime.

Acknowledgment of Understanding:  I have read this document in full, including and not limited, my full intake form, policies for payment and cancellation, Authorization for Work and Explanation of Service (including waiver of liability and indemnity agreement).  I fully understand its terms, and understand that by signing the below electronically I choose freely to give up any right to claim and/or to sue Jenifer Shapiro and I take full responsibility for my choosing to work with her.  I acknowledge that I am signing this agreement freely and voluntarily, and intend by my entering my name below as my electronic signature to a complete and unconditional release of all liability and assumption of risk and agree to hold Jenifer Shapiro harmless to the greatest extent allowed by law.

Please choose your response below and sign the form to complete the intake process. *

Thank you for taking the time to fill out this form!  I look forward to assisting you!

Blessings,

Jenifer Shapiro

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