Registration Form

  • Registration Form

  • Dear Friend:


    The Voice in the Wilderness Mission would like to thank you for choosing our program to assist with your health needs. Our program has been designed to help in the health and healing of the whole person. Our goal is to teach you the causes of disease, its prevention, and its cures. Education is the key to good health and our Ten-Day Cleansing Program is designed to provide you with a broader awareness of what constitutes good health and how to maintain it.

    Our accommodations are home-like and simple, yet clean and comfortable. Don’t forget to leave the stress at home and come to relax and enjoy!

    What to Bring

    The following items are things you will need to bring with you for your stay with us. Please bring warm comfortable clothing enough for ten days (Even during the summer months the morning temperatures tend to be cool in the mountains), water shoes, a bathing suit (for steam bathing), a warm or heavy robe, shower cap, warm night wear, any personal items, flashlight, pen and notebook, and any personal reading material or craft.

    SORRY! NO PETS ALLOWED!

    Please fill out the information required on this registration form to enroll  in a scheduled Ten-Day Cleansing Program. When this form is completed, please mail it to The Voice in the Wilderness Mission, 173 Bush Road, Savoy, Massachusetts, 01256. Or fax to: 508-635-9651.

  • Personal Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  •  - -
  • Sex:
  • Relationship Status:

  • Financial Information

  • What payment method will you be providing?
  • Credit Card Information:
  •  - -

  • Please call to verify your program package price.

  • Arrival & Transportation Information

  •  - -
  • How will you be arriving?
  • Rows

  • Call for updated pricing. Prices subject to change without prior notice. Prices are one-way and are to be paid directly to the driver. Prices do not reflect a tip.

    To schedule a pick-up from Uber or Lyft.

    UBER.COM or LYFT.COM

    Application Details


    Upon returning your application, it is important that you include a deposit (1/3 of total fee). We cannot guarantee any reservation without a deposit, and reservations are not confirmed without your deposit. Deposits are non-refundable, but may be applied to a rescheduled program within a four-month period. The remainder of your balance must be paid upon arrival. We do not provide payment plans. Sorry. If you have any questions or concerns please feel free to call us at this phone number during office hours, 9 am- 1 pm. 413-743-9743. The best time of the day to register is before noon. 

  • GENERAL HEALTH INTAKE

  • Health Information

  • Have you ever had surgery?
  • Do you have any known viruses? (Hepatitis, STD’s, AIDS, HIV, etc.)
  • Are you frequently cold or chilly?
  • Is your skin often cold to the touch?
  • Do you experience pain or discomfort in your head, trunk, or limbs?
  • Do you have allergies to external stimuli, like chemicals, latex, pollen, animal hair, dust, etc.?
  • Do you have problems with your scalp, hair, or skin?
  • Do you experience frequent colds or infections?
  • Do you experience shortness of breath?
  • Do you experience heart palpitations, rapid or irregular heartbeat?
  • How many bowel movements do you have per day?
  • Are your bowel movements difficult to pass?
  • Do you have any recurring issues with diarrhea or loose stools?
  • Do your bowel evacuations smell foul or putrid?
  • Do you frequently feel gassy or bloated?
  • Do you experience persistent heartburn or acid reflux?
  • Is it your desire to do whatever is necessary to regain your health?

  • Medication & Nutritional Supplement List

  • Rows

  • Nutrition & Dietary Information

  • What is your diet preference?
  • How many meals do you eat in a 12-hour day?
  • At what times are these meals eaten?
  • Do you allow a 5-6 hour no eating break in between meals?
  • Do you sit down to eat your meals?
  • Do you eat late at night or before bedtime?
  • Do you snack in between meals?
  • Do you eat refined white flour or white sugar?
  • Is your diet high in fat and cholesterol?
  • Do you eat fried foods?
  • Do you crave sugary or salty foods?
  • Do you crave non-food items? (chalk, dirt, paint chips, baby powder, ice, etc.)
  • Do you consume lots of fresh fruits and vegetables?
  • Do you eat fruits and vegetables at the same meal?
  • Do you use a microwave oven?
  • Do you use aluminum cookware?
  • Do you drink liquids with your meals?
  • Is your diet high in sodium?
  • Do you eat a lot of imitation vegetarian meat products?
  • Do you partake of any food or drink that contains caffeine? (Example: coffee, tea, some sodas, energy drinks, chocolate, caffeine pills or some chewing gum, etc)
  • Do you drink non-caffeinated beverages like
  • Rows

  • Physical Activity

  • Do you do any physical exercise?
  • How many times a week do you exercise?
  • Do you exercise outdoors or indoors?
  • Do you use weights in your workout routine?
  • Do you do any resistance exercises? (Any exercise that goes against gravity like jump rope, swimming, mini trampoline, walking up hills, etc.)
  • Do you enjoy outdoor recreation? (Walking, hiking, boating, gardening, fishing, camping, etc.)
  • Do your muscles cramp during exercise?
  • Do you become abnormally breathless or dizzy during a workout?
  • Do you ever experience chest pains while working out?

  • Water

  • Do you drink at least 8-10 glasses of water daily?
  • Do you experience excessive thirst that causes you to drink more water than necessary?
  • Is your urine pale yellow in color or dark yellow?
  • Do you crave very cold water or ice?
  • Do you ever take a sauna or steam bath?
  • Do you bathe regularly?
  • Do you use soap, deodorant, or body wash gels when bathing?
  • Do you ever end a warm bath or shower with cold water?
  • Do you frequently feel the need to drink water during the night?

  • Sunlight

  • Do you spend time out in the sunlight daily?
  • is it natural light or artificial light?
  • Do you tend to easily burn, or peel when in the sun?
  • Do you use sunscreen?
  • Do you take doctor prescribed medications that prevent or limit you from being in the sun?

  • Temperance

  • Do you smoke? (Cigarettes, cigars, pipe, marijuana, etc.)
  • Do you drink? (Alcohol, beer, wine, etc.
  • Do you use recreational drugs? (Mind-altering drugs like crack cocaine, LSD, heroine, narcotics, etc.)
  • Have you ever used recreational drugs?
  • Do you overeat?
  • Are you a workaholic? (Work too much)
  • Do you over study?
  • Do you spend an excessive amount of time on the computer, cell phone, tablet, etc.using the Internet, social media, games, or email?

  • Air

  • Do you have daily access to pure fresh outdoor air?
  • Do you work or sleep in an air-conditioned room?
  • Do you sleep with a window-cracked open at night?
  • Do you work indoors?
  • Do you have difficulty taking in a deep breath of air?

  • Rest

  • Do you sleep soundly?
  • Do you get up often in the night to urinate?
  • Do you feel rested and refreshed upon rising?
  • Do you feel tired during the daytime hours?
  • Do you fall asleep easily whenever you sit still?
  • Do you work full time or part time?
  • Do you work a night shift job?
  • Are you aware if you snore or sleep with your eyes half open?

  • Trust in God’s Power

  • “And the peace of God, which passeth all understanding, shall keep your hearts and minds through Christ  Jesus.” Philippians 4:7


    “I can do all things through Christ which strengtheneth me.” Philippians 4:13

  • Do you believe in God?
  • Are you developing your mental and spiritual capabilities by daily Bible study andprayer?
  • Do you frequently experience worry, stress, or anxiety over life’s difficulties?

  • Social & Family Relationships

  • Are you married?
  • How would you rate your married life?
  • Do you have children?
  • Are your children very young, teens, or are they adults?
  • Do you have a good relationship with all members of your biological/adoptive family?
  • Do you enjoy close friendships or prefer to be alone?
  • Do you suffer from social anxiety? (Become excessively anxious or nervous around people)

  • Emotional Health

  • Do you consider yourself to be a happy person?
  • Do you love and respect yourself?
  • Are you often depressed or gloomy?
  • Do you live in constant fear?
  • Do you tend to hold onto a grudge for a long time?
  • Do you consider yourself to be an angry person?
  • Do you consider yourself to be a perfectionist? (Everything has to be “perfect” or it drives you crazy)
  • Do you find yourself often crying for no reason?
  • Do you experience frequent mood swings? (Sad one moment and happy the next)
  • Do you suffer from ADD or ADHD?
  • Do you have an eating disorder? (Bulimia, anorexia, etc.)
  • Do you experience frequent panic attacks?
  • Have you been medically diagnosed with any mental health issues?

  • Thank you for taking the time to fill out this form.

  • CONSENT FORM FOR NATURAL THERAPIES

  • I,      , whose current address is      herby
    authorize The Voice In The Wilderness Mission, its hygienic practitioners, staff assistants,
    volunteers, and other attending personnel associated with or designated by them to admit me to
    their natural therapies program and treatment facility located at 173 Bush Road in Savoy,
    Massachusetts, and I herby record my consent for the same to perform upon me such diagnostic
    procedures and such natural therapeutic procedures involved in the (check appropriate box)      3 Day program,      5 Day program,      10 Day program as they, in exercise of professional judgment, decide are necessary for my continual treatment and care. It is my intention to consent not only to such procedures which have been anticipated, but to such further diagnostic and other natural therapeutic procedures which may become necessary or deemed advisable in the professional judgment of the Hygienic practitioner and other attending personal and as my treatment care continues.
    The nature and purpose of the procedures, and expected discomforts, risks, complications, and
    benefits, if any have been fully explained to me. I am aware that the administration of natural
    therapies is not an exact science and results cannot always be anticipated. I also acknowledge that
    no guarantees or assurances have been made to me concerning the results from the procedures. I
    recognize that it is my responsibility to fully disclose to my attending hygienic practitioner any
    physical or emotional conditions and medications currently taking or recently taken which may be
    detrimental in any way to the success of the natural therapy procedures or to my ultimate recovery.
    I also understand that any medications that I am currently taking, is my personal responsibility to
    continue to dispense, and take as prescribed by my medical doctor. And any discontinuance of this
    medication regiment is my personal decision and choice and I will assume all responsibility for any
    negative effects this may have upon my health.
    I have been given the opportunity to ask questions and all of my questions have been answered
    fully and satisfactorily.
    This consent is not only to the hygienic practitioners, staff assistants and other attending personnel
    of The Voice In The Wilderness Missions to whom I have entrusted my care, but to others
    associated with or designated by them. In granting this consent, I intend to assume the risk of
    possible unforeseen results and to be legally bound.

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  • If patient is unable to sign or is a minor, complete the following: Patient is a minor      years of age or is unable to sign due to,      

  • Should be Empty: