Request for Reiki Distance Healing

(Please note: If your browser does not support forms, you can e-mail your request to: Rev K. You may want to print
this page so you have a list of the information to include in your message.)

If you would like to receive a Reiki distance healing and experience Reiki energy for yourself, or if you would like to request
a treatment for another person or pet, please complete the form below. If you would like to know more about why I offer
this free service and what you can expect, please click here.

This is a free service.


  1. Today's Date: 
  2. Who is to be treated?

  3. Self
    Other Person
    Pet
    Name of the Receiver: 

    Age of Receiver: 

  1. Where (City, State/Province, Country) is the Receiver Located?

  1. Reason for healing request (please be brief):

  2. Reason: 
  1. If possible and appropriate, it is helpful to have a brief physical description of the receiver.

  2. Description: 


We would appreciate a note by e-mail after healing is received. Please tell us if you felt any change in your physical, mental, or emotional condition, or even if you felt nothing at all -- we and our healing guides appreciate the feedback!

Your e-mail address will be used to acknowledge your healing request.
Your email address: (e.g.: [email protected]) 

Would you mind telling us how you found your way here?
How you found us: 

This is a free service.

Please note:
When you have pushed the Send Request button, your request is sent and the contents of the form remain on the screen. Please only push this button once.

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