1-1 Sessions

SUBMIt A Waiting List Application

Thank you for joining my private practice waiting list. Please take a moment to complete the information on this form. To consider your application, I need to have a brief explanation of the work you’d like to commence with energy healing and with me. Be sure to include this information in the space below.

1 on 1 Session

Thank you for your interest in joining my private practice. Please take a moment to complete the information on this form. Be sure to provide me with a brief explanation of the work you'd like to commence with energy healing and with me. I'm excited to learn more about you, and welcome you to my private practice.

Personal Details

First Name

Last Name

Please briefly describe the issue you're seeking to evolve/resolve. (45-60 words)

How did you find my practice?

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, I'll review your information and email you a link to progress to the scheduling and payment process for an initial session or for a package of 5 sessions at a 25% discount, and a FREE registration to CLEAR ($199 value).

“I do this work because I believe in the body’s innate ability to heal. I believe in the process that occurs when someone moves into inner alignment and energetic coherence.”

Jill Leigh