Please identify and describe yourself:

Name
Date of birth
Sex	Male Female

• Your Email Address: 

• Your first choice date for your Reiki Session:      Month Jan Feb Mar April May June July Aug Sept Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

         time of day  (Eastern Daylight Time)    1 2 3 4 5 6 7 8 9 10 11 12 AM PM Noon

• Your second choice date for your Reiki Session: Month Jan Feb Mar April May June July Aug Sept Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

         time of day  (Eastern Daylight Time)    1 2 3 4 5 6 7 8 9 10 11 12 AM PM Noon

Please tell me why you're interested in having a Distance Reiki Healing Session: (Specific healing needs, you just want a 'tune up', curiosity, etc.)   Include anything else you think would be helpful for me to know:

Please indicate the method of communication you'd like to use for our pre- and post-session discussions:

                             ICQ Chat      Your ICQ Number:

                             Yahoo Chat   Your Yahoo ID:      

                             Telephone     Your Telephone:    

 

Thank you for your interest in Reiki Distance Healing!

I'll check my schedule then contact you via email to confirm one of your selections for your appointment.

*** The sliding fee for your session is $45 US Dollars, via PayPal or Postal Money Order.  If the fee scale is a hardship for you, please tell me so in the comments section above, in which case we can make other arrangements.

Namaste,

Starr B.