Client Registration
Over 30 years of helping those whose lives have have been touched by adoption
  If you are going to be paying by Credit Card, the address you give must be the address at which you receive your Credit Card Bill.  SiteLock

Keep in mind that the purpose of the healing weekend is to focus on healing the wounds caused by the separation
of mother and child and to provide tools to enable you to continue your healing from this trauma at home.
   *  = Required
 *  Salutation   Mr.    Mrs.     Ms.       *  First:           *   Last: 
 *  Street 1:                     Street 2:   
 * City:    * State/Prov:      Zip:    * Country:  
 *Home Ph:   Bus. Ph: Cell: Skype name:

     I am: Adoptee        Natural Mom             Other: 

Brief reason for requesting psychotherapy  ->     
 Facebook name:    Facebook URL   
 * Emergency Contact:    * Relationship to you       *Phone      
* E-mail:  *     Confirm  E-mail:
*   By placing an 'X' in the box to the left, I agree to give 24 hours if I have to cancel an appointment or
                 I will  be  responsible to pay for the session.
*   By placing an 'X' in the box to the left, I  agree to be responsible for paying for my psychotherapy
Payment Information
   * I will be paying  by      Name on Card  
  Card Number    Card Expires       * Security Code  What is a security code?
Comments  ->    If  Not paying by credit card, enter 00 in the Security Code Box above.
Please press the SUBMIT button below

Signature _______________________________________        Date ________________   
me  at joesoll@adoptionhealing.commailbox

Last Updated on January 18, 2017  by Joe Soll