Client Registration Form Name(Required) First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Permission to email Yes No Sign me up for newsletter and offers Yes No Cell Phone(Required)Permission to leave message or text Yes No Home PhonePermission to leave message Yes No Birthdate (MM/DD/YYYY)(Required) Gender Occupation Referred by: If you found Voss Wellness online, what were you searching for? Please mark any of the following sites that helped us connect: Yelp Google NextDoor Facebook What is your main goal?If you are currently seeing a physician or counselor for this issue, please note: Provider's First Name Provider's Last Name City PhoneCurrent Prescription Medications:Please CHECK all TRUE statements below: I have not been diagnosed with schizophrenia, bipolar or borderline personality disorders. I have not contemplated or attempted to end my life within the past year. I do not have a licensed provider for mental or physical health for this issue. EMERGENCY CONTACT Contact First Name Contact Last Name Relationship PhoneCLIENT COMMITMENT I understand this work is for my personal growth and development. Our sessions are meaningful to the extent I am honest with myself and my guide and open to possibilities. I come to these sessions willing to learn tools to help me be more successful. I understand these sessions are for myself and my personal development, and that if anything is interfering with my ability to concentrate, it is my responsibility to let my hypnotherapist know. No matter how deeply relaxed I may become, a part of me is always listening and is free to ask for any adjustments I may need. I hereby commit to keeping my word to myself. My Commitment I hereby commit to keeping my word to myself. Please read the following disclosure for our policies on cancellation, privacy, refunds and for our services and training. Your signature is required at the end. PRIVACY & CONFIDENTIALITY Voss Wellness adheres to strict standards of privacy and confidentiality. Clients have a right to expect that information revealed in sessions will not be disclosed without express permission unless required by law or essential for public safety. Audio and/or video capture of sessions, or material created specifically for a client, may be shared only with the client or consulting/mentoring therapists for training, documentation or therapeutic purposes. FEES & CANCELLATION POLICY Voss Wellness sessions generally last from 75 to 120 minutes. Multi-session packages are available at discount. Packages of sessions are offered at a discount to encourage your commitment to yourself. They are not refundable except as required by law. Package sessions should be used within the recommended time frame and must be used within one year of purchase. Smoke-Free Living includes support of up to 3 additional sessions within ONE year of the initial appointment. We respect your time and do not overbook, so please be ready to start for your appointment time. If we haven’t heard from you by 15 minutes after start time, that session is considered forfeit. You may reschedule a session with no charge if 24-hour notice is given. Online sessions require a steady internet connection and work best when you have headphones and a quiet and comfortable place where your attention is not needed elsewhere. Interruptions on your end are your responsibility (although we can usually adjust quickly.) Cancellations with less than 24-hour notice shall be billed as if the session had been used. Returned payments will incur a $25 charge. We respect your rights as a consumer. Any concerns that are not resolved to your satisfaction may be addressed with the International Medical and Dental Hypnotherapy Association at (570) 869-1021. SERVICES & TRAINING Stephanie Voss has acquired the following specialized education, training, experience and qualifications in hypnotherapy: * Smoking Cessation Specialist, Ken Guzzo Protocol, 2022 * Member, International Medical & Dental Hypnosis Association * Member, International Society for Investigative & Forensic Hypnosis * Founding member, The Addiction Project * Trauma Resilience Model (Level 1) * 5-PATH & & 7th PATH certified practitioner, Cal Banyan Training Institute, 2010 * Hypnobabies Certified Hypnosis Instructor (HCHI) #137, August 2009-2016 * Medical Hypnotherapist, training by Seth-Deborah Roth, Oakland, CA * Certified Hypnotherapist #108-153, American Council of Hypnotist Examiners, The Hypnotherapy Academy of America, Santa Fe, NM, 2007 * Irritable Bowel Syndrome Hypnotherapy Certificate, 2007, Alabama Hypnotherapy Center * Certificate in Clinical Hypnotherapy, 2007, awarded by Professional Associates in Clinical Hypnotherapy, Dr. Eleanor Field, director * Certified Hypnotist, 2007, Hypnosis Motivation Institute, Tarzana, CA 91356 * Medical Hypnotherapy Specialist, sponsored by the American Board of Hypnotherapy I have read and understood the information above and am ready to work with Stephanie Voss of Voss Wellness.Signature(Required)Date(Required) MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
