Retreatant Form

Date

Name*

First Last

Email*

Main Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you ever experienced a personal empowerment retreat before?*

What was/is the impetus behind booking a private retreat?*

Choose all of the items you wish to be a part of your retreat. (choose multiple by holding down the shift and arrow keys.)*

What are you hoping to achieve or change in your retreat?*

If you had the exact experience you are hoping for, what would be different after the retreat?*

Is there anything you are concerned about in booking your retreat?*

What excites you the most about your upcoming retreat?*

Is there anything Jenifer should know about you, your health or anything that would help her better understand your personal situation/needs?*

Personal Responsibility/Authorization for Work*

By Checking this box you agree electronically to the below indemnity.

I authorize Jenifer Shapiro to perform coaching, NLP, IRT, hypnotherapy and/or holistically-oriented techniques with me before/during/after my retreat/sessions for the purpose of enhancing my life, growing my business, healing, changing unwanted habits, releasing stress, or for other purposes that I may request. I understand that these procedures are not replacements for medical advice and take full responsibility for ensuring that I and/or my child receive proper medical attention as required. I understand that the success of the session(s) depends largely on the client's willingness and desire to take control of their life and make the changes they wish to see. I recognize that hypnotherapy and other holistic practices can be important tools in this process. I realize the results of the session may vary and that Ms. Shapiro cannot guarantee nor determine the results of the therapy prior to or after the sessions. I am aware as well that Ms. 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 recognize that I have other choices in seeking assistance that at this time I have chosen to work with Jenifer Shapiro. I authorize Ms. Shapiro to perform work with me in a professional manner and will take responsibility to discuss with Ms. Shapiro any techniques that I have concerns about or are uncomfortable with. I take full responsibility for requesting to work with Ms. Shapiro and I state that all information that I provide to Ms. Shapiro is completely true to the best of my knowledge. I state from fact that I am in good physical condition and have not been advised by a medical professional not to engage in hypnotherapy or other treatments. 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 whom I may bring to her willingly. Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am electronically or manually signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability, assumption of risk and agreement to hold harmless and indemnify to the greatest extent allowed by law.

Please check the below for security. TY!

Retreatant Intake Form