Application Form

I am a...(required)

New Customer

Returning Customer

First Name

Last Name

Female

Male

Age

Phone Number

Mobile Phone Number

Date of Birth

Email

Please let us know if you have any changes to your contact information

Street Address

City & Country

Please select a course

3 Session Starter Course - $60.00

Continued Course - (10 sessions) $200.00

Special Course - (20 sessions) $300.00

Please describe any new issues or updated information regarding what you would like help with(required)

I would like services for...(required)

Myself

Someone else

Desired Start Date(required)

Their Name

Full name of the person to be healed.

Their Gender

Female

Male

Their Address

Please enter the address of the person to receive healing.

If the location where you/they would like to receive healing is different from the home address, please specify

Describe what you would like help with ( conditions, symptoms, illness, etc.)(required)

Please include a recent picture of yourself / person to receive healing.(required)

Browse...

Please include a recent picture of yourself/person to receive healing if it has been over 6 months since your last session.

Browse...

Maximum size 10MB

For Direct Healing or Ki Energy classes, please pay in cash.

Payment Method(required)

PayPal (Credit Card or Bank Transfer)

You won't be charged until we have made an appointment arrangement with you. You can change the method of payment later on if you like.

Tell me how you heard about me (website, friend, family member, hotel, other)

Type the characters(required)