Healing Assistance Program Application
Welcome!  Thank you for your interest in The Space Wellness Center.  This program was created to provide the opportunity for healing to all people who have been called to this journey regardless of one’s ability to pay.   There is a place for YOU here.

Please answer all questions below. Once received we will schedule an appointment to sit with our HAP Coordinator Susan Martorello  We will then begin the process of connecting you to our experienced healers and teachers that will provide you with a unique opportunity of health and healing.

Note: All information will be kept confidential and used solely for administrative purposes. Your data will not be shared without your consent.
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Name *
Email *
Phone *
Preferred Method of Contact *
Please tell us about you.  What brings you to The Space? *
How do you think we can help you? *
What are your financial needs at this time? *
Are you under the care of a physician? *
If "yes" please describe diagnosis and share any pertinent information.
How did you hear about us?
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