1-1 Sessions

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.

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.

Personal Details

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

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. Should there be space available, and a good fit between us, you'll receive an email with a link to progress to the scheduling and payment process for an initial session.

“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