Reiki With Trust LLC

Distance Healing Request Form
Short Term Intensive Sessions

Please complete the form below. If you do not get a confirmation within three days, please contact me. We all know what can and does happen with electronic communication! Before, submitting, please check for typos, especially your e-mail address.

Reiki Distance Healing - Convenient & Powerful Remote Energy Healing

Treatments will begin upon receipt of this application and completion of the fee transaction.
A confirming e-mail will be sent to the individual contracting treatment upon the initial  sending of the treatment.

Choose one of the following options:

Single Event Treatment - examples: specific one day event, present emotional crisis, audition, surgery, presentation, past trauma, etc. - $37.00
Fourteen-Day Treatment - examples: a single recipient such as self, other individual,  pet, child, situation, business/personal relationships, location clearing, etc. - $77.00

Thirty-Day Treatment - examples: general well being, a situation, business/personal relationships etc. - $147.00

For an approximate conversion from US dollars to YOUR currency, click below.
                                     OzForex Currency Converter

Method of Payment

Person contracting  the Reiki Distance Healing Service.
There have been issues for those Reiki clients who have Yahoo email addresses.
Often my confirmation & other emails are randomly delayed by Yahoo. I ask that you please provide me with an alternate email address. I will receive your email from Yahoo in a timely fashion. The problem is Yahoo slowing down their incoming email...including mine:(

First Name
Last Name
Street Address
Zip/Postal Code
Home Phone
Home e-mail
Birthday  mm/dd/yy
Sex Male Female


Recipient Information
Recipient of Reiki name/description.  Although Reiki can only be received by willing souls, permission is a courteous prerequisite. Filling out this field indicates permission was granted.  

If the Reiki treatment is a gift, a Gift Notification Template is available for you to send to the Reiki recipient. You can send it as an attachment, or cut & paste into an e-mail from you. To cut and paste highlight my text, ctrl C, get to your e-mail page and ctrl V.

Recipient Name/Situation/Event/Business

Recipient e-mail-optional


Briefly describe who or what is receiving Reiki and for what purpose. As always, the energy will be directed to the highest good. It is incapable of less.


Timing of Single Event Treatment (Present/Future/Past)  

Send Reiki to Present event/situation/person
Send Reiki to Future Event
Send Reiki to Past Event

Date of event (optional):
-- mm/dd/yy

Time the event begins (optional):
-- hh:mm:ss am/pm

Referral Information
How did you find or hear of Reiki With Trust LLC- Distance Healing with Anna?
Please include full name of referring individual, source of ad, search engine etc.

Payment Options
1) U.S. Certified/Cashier Check or Money Order 

2) Immediate & secure payment with a credit card.

Upon clicking on SUBMIT at the bottom of this page, you will be presented with the necessary information etc. to complete the payment portion of the registration process. If you are sending payment via the postal system, please remember to print out this completed registration form and include it with the fee.

*If the submit button does not present you will the Payment Page, click here.

 Reiki is to be used as a wonderful compliment to medical/psychiatric licensed  professional care.
 Reiki should not be used as a substitute for professional medical/psychiatric treatment. 

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Before you click the "Submit Form" button, please take the time to check that your information is complete and free of typographical errors.

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Reiki With Trust LLC