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Reconnective Healing Questionnaire

Please describe your reconnective healing experience
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name
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?
May I use your first and/or last name (or initial) on my web site?
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?
Other Comments:

Please enter the word that you see below.