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HEALING FEEDBACK - PERSONAL HEALING REQUEST
Your First Name
Your Last Name
Your E-mail address
When did you request a healing?
When was your request initiated by our Circle?
What was the healing requested for?
Is this a repeated request?
Yes
No
If yes, which healing cycle are you
on?
second
third
fourth
fifth
sixth
seventh
Did you feel any effects to be attributed to the healing?
Yes
No
If the answer is yes, on which level did you feel the healing?
(You can check more than one level)
physical
emotional
mental
spiritual
Other
If the answer is other, please describe
Please describe the effects of the healing in as
much detail as possible
How soon after the healing request was initiated
did you start to feel the effects?
For how long did the effects last?
Please rate how beneficial the healing was to you
If the answer is other, please describe
After your healing was initiated, did you notice any
change in your life, or did any special event happen
that you feel important mentioning.
If the answer is yes, please detail
Are you using a healing journal?
Yes
No
If the answer is yes, please share your feedback
& experiences with your
work with the healing journal
If the answer is no, please share why you choose
not to work with your healing journal
Are you working with your personal
healing affirmation?
Yes
No
If the answer is yes, please share your feedback
& experiences with
the use of your healing affirmation
If the answer is no, please share why you choose
not to work with your healing affirmation
Are you doing your healing exercise as outlined in the
healing initiation confirmation?
Note: This is referring to the special exercise given to you in your
healing
cycle confirmation (e.g. the exercise for the first cycle is a breathing
exercise)
Yes
No
If the answer is yes, please share your feedback
& experiences with
the use of the healing exercise
If the answer is no, please share why you choose
not to use the healing exercise
Would you like to make any other comments?
All of the above information will be treated strictly confidential
and not passed on to any third party.
Thank you!
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