Gift Certificate Form

Treat Your Friend or Loved One to a Gift Certificate!

Would you like to give your friend or loved one the gift of healing? Simply fill out the form below. You can pay in-person, by mail or online with PayPal or a credit card.

Please note that all fields followed by an asterisk must be filled in.

Your First Name*
Your First Name*

Your Last Name*
Your Last Name*

Your E-Mail*
Your E-Mail*

Your Street Address*
Your Street Address*

Your City/State/Zip*
Your City/State/Zip*

Your Phone No.*
Your Phone No.*

Length of HeartMind Healing Session*
Length of HeartMind Healing Session*

	60-Minute Session
	90-Minute Session

Number of Sessions*
Number of Sessions*

Recipient's First Name*
Recipient's First Name*

Recipient's Last Name*
Recipient's Last Name*

Recipient's E-Mail*
Recipient's E-Mail*

Recipient's Address*
Recipient's Address*

Recipient's City/State/Zip*
Recipient's City/State/Zip*

Recipient's Phone No.*
Recipient's Phone No.*

How Would You Like the Certificate Delivered?*
How Would You Like the Certificate Delivered?*

	Mail it to Recipient
	Mail it to me
	I will pick it up

How Will You Pay?*
How Will You Pay?*

	Online
	Check (Via Mail)
	Check or Cash (In Person)

Optional Comments

PLEASE NOTE: Each Gift Certificate has a three-month expiration date. I will contact your friend or loved one two weeks before the expiration date if I haven't heard from them by then. (This is why I require the Recipient's e-mail address and phone number). I will inform you if the Recipient has not contacted me to make an appointment by the time the Gift Certificate has expired.

At that point, ownership of the Gift Certificate will revert to you. Once it has reverted to you, you can either use it yourself or give it to another friend or loved one.

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