Hearing Voices Research

Remote Spirit Release

Hearing Voices Research Participation
Your name (Referrer):*

Use the drop-down for your correct prefix. First Name initialLast Name
Your connection to the patient. i.e. I am the patient's*

Healthcare supervisorSpouse/partnerParent or grandparentSon/daughter/grandchildSiblingClose friendOther close connection
Your E-mail*
example@example.com
Do you have agreement with a supervising professional?*

Yes
Supervisor's name*

Use drop-down for prefix.First name initialLast Name
Position*

PsychiatristPsychiatric nurseMedical doctorPsychologistLicensed therapistSocial workerReligious or spiritual ministerPolice, probation or prison authority
Supervisor's email*
example@example.com
Healthcare supervisor's Institution*

Hospital/clinic/office name

Address

CityState

Zip CodeCountry
Patient's name*

First NameLast Name
Patient's current residence*

With familyHospital or care homeIn jailOther place
Patient's current location*

Residential institution name if not at home.

Street Address

CityState / Province

Postal / Zip CodeCountry
Patient's gender*

MaleFemaleTransgender
Patient's age*
Ethnicity*

White CaucasianHispanicCaribbeanAfricanAsianOrientalMixed raceOther non specific
Religion*

NoneChristianIslaamJudaismBuddhistHinduOther
Does the patient hear voices?*

Yes
Medical diagnosis*
Research fund contributor*

Use drop down for your correct prefix. First NameLast Name
Contributor's email*
example@example.com
Type of contribution*

Registered PatronFree will donation
Please verify that you are human*
Should be Empty:

Remote Spirit Release