My First Form

Relax Inner Peace

Please complete the form below:

To Request a Distance Energy Healing

If you are interested in receiving Distance Energy Healing for yourself, a family member or an animal, please fill out the form

below to receive the universal life energy. I use this picture, along with your full name to visualize the healing.

You can also send your Distance Energy Healing request by email to david@relaxinnerpeace.com

If the healing is for someone else, I will also need their written permission - I ethically cannot work on them

without this permission. (A parent may give permission for a minor.) If you are unable to obtain permission, please

explain why. I will consider this on a case by case basis. If I am unable to obtain permission for the healing from

the Higher Self, I will refund your money.

Distance Energy Healings are generally done in the quiet moments of the day - early in the morning or later in the

evening. Many will feel little during this time, but some more sensitive persons may actually feel the energy I

conduit to them, it may be warmth or tingling or even visions. No healing can hurt you, it will seek the area or your

mind, body or soul that needs the most attention.

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Please list other holistic therapies you have experienced:
Personal Goals you may have:
Please list current conditions for which you are receiving doctor's care:
Please describe any feelings, symptoms or problems you may be experiencing:	*
Personal Health Goal
- I agree to update Relax Inner Peace in any changes in my medical profile and understand Relax Inner Peace is not held liable should I forget to do so. - I understand holistic therapies should not be construed as a substitute for medical examination, diagnosis, or treatment of any medical condition.I should see a physician or other qualified medical specialist or counsellor for any physical or mental ailments. - Holistic therapies are provided for the basic purpose of relaxation and relief of muscular tension or stress. Through the relaxation process, holistic therapies may assist to promote balance and normalization of the body naturally. - I understand that the practitioner does not double book appointments and arranges his schedue to accomodate me. Therefore I understand there is a cancellation policy. I may cancel my appointment up to 24 hours before it is scheduled, otherwise I will be charged for the full amount. - I confirm to the best of my knowledge that the answers I have given are correct, and that I have not withheld any information that may be relevant to my session. - I am aware that my rights to privacy wil be maintained. No use of my name or likeness (picture) will be made without my written consent, in accordance with patient/client confidentially.
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