Jill Leigh PAYMENT FOR SESSION Sessions Payment Form Please be sure to plan your time and pay for a 1.5 hour initial session with me. I'll be in touch to schedule your session when I receive payment from you. I'm looking forward to working with you. If you are human, leave this field blank. Name First Last Last Email Address Line 1 Street address, PO Box Address Line 2 Apartment, suite, unit, building, floor, etc Town/City State/Province Postcode/Zip If you don't have a postcode or Zip, please write 'No Postcode' Country Additional information you would like to share with Jill. Select appropriate payment amount 337.50 - Initial Session 225 - Subsequent Session Credit Card Credit Card Credit Card Credit Card 1 2 3 4 5 6 7 8 9 10 11 12 Credit Card 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 Credit Card When completing this form, your name and email will be collected only for the purpose of confirming your payment. 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
