Request for Distant Healing

This is a free service.

Date: 

who is to be treated?
Self
Other Person
 

Particulars of Patient

Name:            

Age:                

Sex:                 

Address:         

City:                    

State/Province: 

Country:             

Would you like to receive any intuitive feedback that comes during the treatment?

Yes                    No

Your e-mail Address:    

Requesting healing for the following condition(s):

( Pls. indicate Healer's name for follow up request )

Please note that some of our Healers need a location to be able to focus their efforts. If the patient is in hospital, please provide name and location of hospital. Our Healers may not be familiar with the usual practice of abbreviating state names. If you could remember this when completing the form that would be helpful to us in managing your request.