Request Form
Please make sure you fill out all of the fields below before you send your form.
Missing information will result in the loss of your request.
Thank you.
Enter your full name:
Enter your email address:
Enter your full birthdate (MM/DD/YYYY):
Enter the city and state where you currently live (if outside USA, enter city and country):
Please state your healing request:
DISCLAIMER: By checking the box below, I certify that: (a) I am 18 years old or older. (b) I understand that this service is completely without charge. (c) I understand that the service offered (spiritual healing) should not replace care from any medical, legal or other licensed practitioner. I understand that I may receive occasional e-mails from Rev. Jeff regarding website updates and/or special offers. I understand that my privacy is protected and my personal information will never be sold, rented or given out to anyone. I understand that I can stop receiving periodic e-mails by simply replying to the message with "unsubscribe" in the Subject line.
Yes
