Your Name (required)
Your Email (required)
Address
Telephone
Previous healing background (Level of healing work you do, certifications, licenses etc. as well as healing work you have received)
Are you in private practice?
Do you work in person with your clients or long distance or both?
What are you current healing concerns? (physical, emotional, or spiritual)
Do you take prescribed medications, anti-depressants or psychotropic drugs? Or have you in the past?
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