SouthEast Regional Pranic Healing Centre

Distance
Healing Form

Pranic Healing is a ‘no touch’ healing modality. The Natural Law of Interconnectedness and Directability allows the client to receive the Divine healing energy regardless of the physical location of the Pranic Healer. We offer distance healing for physical and psychological ailments. A photograph of the person who is to receive the healing is requested in advance, and Healing Form--Part One must be completed and submitted. We will call you to set up appointment dates and times and ask that you schedule the required, uninterrupted time for the session. We request that you bathe or shower before the session and that there be no distractions (i.e., phones, TV, family members, etc.) during the healing session. You may have soft music in the background and may sit or lay down. We will need you to complete Healing Form--Part Two the following day to share your experiences and feedback. A video link is also available at the Centre with Skype or FaceTime.

Fee Schedule: $90.00 First Session, approximately 2 hours

$60.00 Followup Sessions, approximately 1 hour

Please contact the Centre for payment details

HEALING FORM--PART ONE


The Center for Pranic Healing, Inc.
290 Grant Avenue, Lyndhurst, New Jersey 07071
877.787.3792 v 201.896.8501 f
CONFIDENTIAL HEALING FORM
PERSONAL INFORMATION
First Name:
Last Name:
Street Address:
City:
State:
Zip Code:
Occupation:
Date of Birth:
Gender:
E-mail Address:
Contact Phone Number:
How did you hear about Pranic Healing and/or who referred you?
MEDICAL HISTORY
Do you take any prescription drugs?
If yes, specify for what ailments:
Do you have a history of contagious disease(s)?
If yes, specify what ailments:
Do you have a history of any serious physical injury(ies)?
If yes, specify:
Do you have a history of any psychological disorder(s)?
If yes, specify:
Other pertinent medical history:
HEALING INFORMATION
Please describe current condition and/or symptoms:
A) Minor Ache(s):
B) Major Ailment(s):
Pain or Discomfort Level
Using the above scale, please indicate the current level of pain / discomfort / symptoms BEFORE the Pranic Healing Session:
A) Minor Ache(s):
B) Major Ailment(s):

HEALING FORM--PART TWO


Using the following scale, please indicate the current level of pain / discomfort / symptoms AFTER the Pranic Healing Session:
A) Minor Ache(s):
B) Major Ailment(s):
Symptoms Improved:
Please detail how your condition and/or symptoms have improved:
A) Minor Ache(s):
B) Major Ailment(s):
DISCLAIMER: I, the recipient, understand that Pranic Healing is not meant to replace conventional medicine but rather to complement it. If symptoms persist, a medical professional is to be consulted immediately. I hereby release the person(s) providing Pranic Healing and the Pranic Healing organization from any liability as a result of the services received by me.
Signature
Date:
Healer's Name: