Private Energy Healing Consultation

1-on-1 Sessions

WAITING LIST APPLICATION FORM

1 on 1 Sessions Application

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.

If you are human, leave this field blank.

Personal Details

Name *

First

Last *

Last

Email *

Phone Number *

City *

State/Province *

Country *

How did you find my private 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.

If your needs are immediate, and I am unable to take your case, I will be happy to refer you to practitioners who may be able to work with you in a more timely fashion. Please check the YES box if you’d like a referral.

Yes

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

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.