Private Energy Healing Consultation

1-on-1 Sessions

WAITING LIST APPLICATION FORM

Thank you for joining my private practice waiting list. Please take a moment to complete the information on this form. If there’s something you especially want me to know about your process or experience at this time, feel free to add it in the last section below.

Personal Details

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

How did you find my practice?

How long do you feel you can wait before beginning work with me?

Immediate

1 month

2-3 months

4-6 months

If Immediate, please describe your need/interest in 45-60 words.

Anything else you would like to share with me?

When completing this form, your responses will be collected only for us to review your application. Please read our Privacy Policy to see how your data is used and stored.

I consent to have Energy Healing Institute collect my details via this form.

Yes

Next Steps

Once you click submit, you’ll receive an email indicating my next steps, based on the information you shared in this form. Thank you for taking the time to connect with me.