New Client Intake Form for Your First Session

General Client 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. *

Yes, I am legal guardian and completing the form for my child who is under 18.

No, I am an adult over 18 and filling this form out for myself.

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. *

Yes, I am legal guardian and completing the form for my pet/ animal.

No, I am an adult over 18 and filling this form out for myself.

Current Date (MM/DD/YYYY) *

Patient/ Client First Name *

Middle Initial

Patient/ Client Last Name *

Birth Date (MM/DD/YYYY) *

City and Time of Birth if known

Address (Please include full address with zip code for mailing homeopathics) *

Preferred Phone *

Secondary Phone

Email Address *

Is this your first time working with Jenifer? *

Yes

No

If you have worked with Jenifer before, please offer about how long it has been and any changes that have occurred in your diet, health or life since your work together. Thank you! *

Check the areas of Jenifer's work you are interested in. *

Please check any physical ailments the patient/client has now or has had in the past (please explain further below, thank you). *

Please check all that apply to patient/client: *

Check if you smoke - including cigarettes, cigars, marijuana or esigs)

Check if you drink less than 2 drinks per week

Check if you drink more than 2 drinks per week

Check if you have any restrictions to your diet (and see next question)

Primary Reason(s) for Seeking Assistance *

Any symptoms from diagnosed medical conditions? If so, please list and explain below including when they started, how prevalent, etc. *

Any symptoms that have previously been undiagnosed and/or misdiagnosed? If so, please list and explain below including when they started, how prevalent, etc. *

Please explain any dietary restrictions including gluten free, dairy free, food allergies, food choices for any reason including kosher, etc. *

Please give an overview of foods/drinks you normally consume on a daily basis. If you eat three meals, you can list by meal, if not, just a list of normal foods and drinks you consume. *

Are you taking any medications? If yes, please list each including the brand, dosage, reason for taking, if you have felt any improvement or change, and length of time you have been taking it below. *

Are you taking any supplements? If yes, please list each including the brand, dosage, reason for taking, if you have felt any improvement or change, and length of time you have been taking it below. If taking more than 5 supplements, please use the worksheet provided instead and state 'listed separately' below. *

If you have previously taken homeopathics (or your child has if filling this in for them) please list all homeopathics taken, potency of remedy, length of time taken and effects of remedies below. *

Any known allergies (hay, food, chemicals, EMF, etc.) or asthma-type symptoms and if so please explain and what causes them (if known) and/or makes them better and worse. IE. worse on exertion, worse going uphill, worse from eating chocolate or coffee, etc. *

Any major dental work done in the past 2 years (ie. root canals, new crowns, mercury removal, etc. - anything beyond normal cleaning). If so, please offer what and where located. *

Have you moved your home or office or had any major construction, painting, new carpet, etc. done in your home or office since the symptoms began? *

When you have taken medications or homeopathics in the past, have you required a minimal dose (ie. are you sensitive), a normal dose, or a high dose (ie. does it take a lot for you to feel effects such as more than one shot of dental anesthesia or 3 tylenol, etc.). Please explain. Thank you. *

Are you currently under the care of other practitioners/ doctors? If so, please list name, type of practitioner and the work you are currently doing. (I will never another doctor without your written permission, I know many doctors in my field and based on their form of work, may have a better idea of why you were prescribed something and how I can help - this is informational only and if you are uncomfortable, please list only the type of doctor and do not list their name.) *

Everyone's path to healing is unique and everyone's pace is different. Please choose what seems like your way: *

I would like to solve specific current issues only.

I would like to solve specific current issues while I also look at creating a deeper map for overall health going forward.

I would like to look at all of my options for holistic healing including energy work, nutrition, supplements, homeopathy, holistic empowerment counseling and more.

I'm seeking to integrate allopathic care with holistic care.

I'm not sure yet, I would like to see what works for me as we go and I want Jenifer to give me options so I can choose as we go.

If none of these fit, please enter an answer here: If none of these fit, please enter an answer here:

If you received exactly what you are seeking from Jenifer, what would the transformation provide for you and what might it look, feel or be like? (If you don't know yet, that is ok, just think on it a bit and you can discuss with Jenifer in session time.) *

Is there anything else you wish to let Jenifer know about regarding your work together? *

In case of emergency, who may we call, please ensure to offer full name, phone and city/state. Thank you!
*

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 (including supplementation) 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. *

I agree to the terms defined above and within this form in full.

I do not agree to the terms defined above and within this form in full.

Enter your full name as electronic signature here *

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

Blessings,

Jenifer Satya Shapiro

Classical/ Clinical Homeopathy	Herbal and/or Nutritional Counseling
Alternative Healthcare General / Physical Healing	Integrative Bodywork (craniosacral, myofascial, acupressure, spinal release, energy healing, etc.)
Emotional Healing (including PTSD, TRM)	Empowerment Coaching/ Counseling
Spiritual Counseling/ Education	Professional Mentoring/ Training
Business Counseling/ Entrepreneurship	Work with Animals
OTHER (please explain) OTHER (please explain)