Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.JOURNEYS TO HEAL Inc. Hypnotherapy, Breathwork, Life Coaching, NLP, EFT, PLRT, QHHT, Kambo, & Energy Healing w/ Kristine Ovsepian M.A.,C. Ht. 303 N. Glenoaks Blvd Ste. 200 Burbank CA 91502 ~ (818) 605-0089 ~ Kristine@JourneysToHeal.com ~ JourneysToHeal.com AGREEMENT OF SERVICES Please read and acknowledge your understanding of the following explanation of services. The State of California requires that you read, sign, and receive a copy of this full disclosure. PLEASE PRINT YOUR CONTACT INFORMATION Name *FirstLastDate of Birth *Address *Phone *Email *Emergency Contact Name *FirstLastEmergency Contact Phone Number *Occupation *How did you hear about us *Have you Received Energy Therapy Before? *YesNoHave you Been Hypnotized Before? *YesNoFOR OFFICE USE ONLY Fees: First Session: $450 / Regular $500 (includes $50 Yelp/Referral Discount) – 1.5 hour session Additional Sessions: $300 – 1 hr session PLRT/QHHT – $500 / Regular $550 (includes $50 Yelp/Referral Discount) – 2 hour session PAYMENT Initials *Session fees are non-refundable and are subject to change. Payment is due in full, at least 48 hours prior to the appointment time/date. Journeys to Heal does not bill. Journeys to Heal Inc. accepts Visa, MasterCard, Discover, & American Express. Payments by credit card will appear on statements as: “Kristine Ovsepian / Journeys to Heal Inc.” J.T.H. does not submit to insurance. If the clients insurance company covers hypnotherapy/ energy healing/ or other modalities offered by JTH, payment is still required at the time of service. The client is responsible for submitting their claim to the insurance company for any possible reimbursement. PHONE SESSIONS Credit card payment is required at the time of the clients’ phone session. The client is responsible for any phone charges they may incur. APPOINTMENTS hear about Number Initials *To cancel or re-schedule an appointment, a 48 hour notice by phone is required. You will be charged a full session fee or a minimum of $250 for late cancelled appointments, or if you miss an appointment without cancellation. AUDIO COPIES The client may be given an audio copy of the hypnotic part of their session, as a positive reinforcement tool. This copy is for the clients’ personal use only. Never use it when driving or during any activity which requires your conscious or wide-awake attention. CLIENT ACCEPTANCE AND AGREEMENT Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Kristine Ovsepian, Journeys to Heal Inc. from and against any and all claims or liability whatsoever or nature arising out of or in connection with my session(s). I, the undersigned, acknowledge that I have received a copy of this Agreement for Services. I also acknowledge that I have read, understand, and agree to the above terms and conditions for services of this self-improvement program. Signature * Clear Signature Signed By *FirstLastSigned On *Submit
