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Healing Needs Request

Please fill out the following form to help us understand how we can best assist you.

Personal Information

What is your preferred communuation method? Required

Holistic Healing Experience

Are you familiar with any of the following alternative healing modalities. Please check all that apply or however, you want to word that with the online form

Services

Would you be interested in the following services: (Pick top 3) Required
Areas Of Concern Required

Consent

Changed by Fire assumes no liability for the services provided by outside providers to burn survivors. By accepting the services, the survivors agree to hold Changed by Fire harmless from any & all claims, damages and liabilities arising from these services. Failure to arrive for scheduled services will result in forfeiture of future services. This liability statement might be wise to include on the healing request form as well.

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Healing and awareness
located in Phoenix, AZ
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