Art of Healing

A Three-Year Training Program for Healers Taught by Mary Branch Grove and Helen Yamada In Northern Virginia

Name
Bate of Birth
Male
Female
Address
City
State
Zipcode
Home Phone
Work Phone
Email

How Did You Hear About This Program

Friend
Talk
Post Card
Flier
Bookstore
Health Food Store
Health Professional

Life Area

In What Areas of Your Life Do You See That This Program May Help You? Rank them from 1 to 5 with 1 being the most important.	List How The Program Might Help You In This Area Of Your Life

Personal
Career
Health
Relationship
Financial

BACKGROUND What life experiences have you had that may be helpful in taking this program?

PERSONAL HISTORY Share with us your personal biography.

MEDICAL HISTORY List any medical or psychological history, including therapy, chronic problems, injuries or hospitalizations. Please list any medications you are currently taking.

Please send a $200 check for deposit to: Susan Hough P.O.Box 542, Leesburg, VA 20178 If you have further questions you may contact Susan Hough 703-505-5152 shoughlinks@aol.com Mary Branch Grove 703-442-7735