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Prefix:
First Name: *
Last Name: *
Organization:
Phone Number: *
Street Address: *
E-mail Address: *
Address Line 2:
City: *
State:
Postal Code: *
Brief Description of Activity *
Have you ever experienced any of the following *
Voices
Calling of your name from no apparent source
Being touched
Smells/odors
Unexplained lights
Tugging of clothes
Shadows
Apparitions
Orbs
Smoky forms
Sudden unexplained breezes
Cold/Hot spots
Strong Random thoughts
Feelings of being watched/followed
Recent anniversary of loved ones death
Tapping or knocking from no apparent source
Mood changes (especially in one location)
Doors opening/closing
Movement out of the corner of your eye
Electrical disturbances
Furniture moved
Aplliances on/off
Renovations
Puberty/emotional distress of family member
Any medications (prescribed/OTC)
Any disorders/sleep apnea etc
Do you have any special requirements / requests?
Do you feel you or your family are in danger *
Yes
No
Not immediate
Would you want the cause of the activity removed *Yes
No

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