Reconnective Healing Questionnaire

Please describe your reconnective healing experience

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name

E-mail Address*
E-mail Address*

During your Reconnective Healing session, did you see anything such as lights, people, shadows, colors or other? Please describe:

During your session, did you feel anything such as tingling, warmth or coolness, or other feelings? Please describe:

During your session, did you hear anything? If so, please describe:

During your session, did you smell any smells? Please describe:

Any other experiences you'd like to share?

What changes or healing have you noticed since your reconnective healing session(s)?

May I use your testimonal on my website?

	Yes
	No

May I use your first and/or last name (or initial) on my web site?

	Yes
	No

Name as you wish it to apear on my website:

May I link your name to your email address so that potential clients can email you and ask you about your experience?

	Yes
	No

Other Comments:

Please enter the word that you see below.