Healing Practice Payment

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Office Phone
Cell Phone*
Fax
Email*
Occupation
Pay for:*
- New Client Session - 2 hrs - $350
- Returning client - 1 hr - $175
- Returning client - 2 hrs - $350
- Individual Family Constellations Session - 2 hrs - $350
- Supervision - $175
- I will pay the agreed upon amount. (Enter amount below.)
Agreed upon amount
Total
$0.00

Agreement*
By checking this box indicates that I have read, understood and agreed to the terms of this informed consent and release form. I willingly agree to hold harmless and release from all liability the facilitators, organizers, and participants in this workshop.
Memo of Understanding

In consideration of receiving services rendered by Susan D. Ulfelder, I hereby declare as follows:
- That my true and legal name is as signed below and not otherwise.
- That Susan D. Ulfelder has informed me that she is not a medical doctor and I am aware that she is not licensed under the laws of this State to practice any form of medicine.
- That I understand that Susan D. Ulfelder evaluates the human energy field and balances it and that this is not a substitute for medical treatment.
- That I understand that she will neither diagnose nor prescribe for any condition or problem from which I may appear to be suffering.
- That she has suggested, should I have any physical or mental complaints, I should consult a licensed medical practitioner.
- That she has informed me and I understand that no guarantees or promises of cures have or will be made to me and that any benefits which I experience come from within myself.
- That I am 21 years of age or older.

Total
$0.00
Billing Address*
Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Phone*
Credit Card

American Express
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Visa
Card Number Expiration Date Security Code Cardholder Name