Personal Information

Name        

Date of Birth  Age    Email 

Address    

City          State    Zip 

Phone no ( H )    Phone no ( C ) 

Select Distance Healing Transmission Plan

2 Weeks     1 Month     3 Months

Are you adding a family member, friend or pet with your process?

Yes   No

If yes, Names of your family member, friend or pet

1.

2.

3.

Please use a separate form for each person or pet

What is your basic intention to receive Long Distance Healing?

Challenges experienced, where you need help.

( check as many as apply and please explain each one you check )

Physical

Mental  

Emotional 

Social   

Educational 

Occupational 

Financial 

Spiritual  

Specific Questions - Comments - Suggestions :

Signature    Today's date 

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