top of page

We want to make sure you remain happy & healthy.

Please complete all forms AFTER you have booked your appointment under services. The recommendation for a new client is the Listening Hands® Elevation Program or Reiki + Intuitive Healing to give you an overall assessment & a Listening Hands® Holistic Care Plan.

 

30 min consultation is included at the start of your 1st appointment. 

​

All 3 of these forms are NECESSARY for treatment. You also agree to update your Practitioner of any changes to your medical history. (Applying for program payment plans via the last link is optional.)

 

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled. 

Please sign

Please sign

Please sign

Please sign

Upload File

Thank you for Submitting!

Please submit at picture of your ID at this time & present this credit card during your 1st appointment for verification.

 

Now, please complete your Past Medical History Questionnaire below.

Medical History & Questionnaire

Please fill out the following form prior to your FIRST VISIT

to help us understand your needs. This form is NECESSARY for treatment. 

Listening Hands Logo
Have you been hospitalized in the last 12 months?
Are you currently diagnosed with a medical condition, illness, or injury?
Do you have Diabetes? (please eat 1 hour before session.)
Do you have a diagnosis of Depression?
Do you have a diagnosis of Anxiety?
Do you think you have depression and/or anxiety?
Do you have any other mental health diagnoses?
Are you pregnant or nursing?
Do you drink?
Do you smoke or vape?
Ingest THC or CBD?
Have you ever had a Reiki Session or Energy Healing Session?

Please Read & Sign Next Line

Listening Hands LLC is a healing space for holistic therapy & spiritual counseling.
 

I understand that the service is being provided by practitioner of Listening Hands LLC at my request. I understand that the service is complementary to and separate from medical services licensed by the state. I agree to hold practitioner & Listening Hands LLC harmless and understand that practitioner is not responsible for the outcome of the session.

Any information you share with practitioner during our session is always kept confidential except for special instances in which information is shared with the practitioner that must be reported by law. I understand that insurance is not accepted, no paperwork will be filed with my insurance, and I will not receive any medical or mental health diagnosis at the completion of service.

​

By signing this form, I certify that the above information is correct to the best of my knowledge. I give my consent for the purchased session. I understand that I may discontinue a session or sessions at any time for any reason, and if I feel at all uncomfortable, I should tell my practitioner. I understand that there shall be no liability on the practitioner.  Practitioner also reserves the right to refuse service to anyone for any reason such as inappropriate speech or conduct. By signing below, I acknowledge that I have read and understand all parts of this consent/intake.  I consent to the service(s) in which I booked, as well as the charge incurred as listed on the website during booking of service(s). 

Please hit submit form before proceeding to the next form. You will see a red confirmation message if your form has been submitted correctly. Thank you! 

© Listening Hands LLC

*Thank you!
Your form has been submitted. All information is confidential.
 

simone-hutsch-_wpce-AsLxk-unsplashcrop.j

Ready to get started in a program now?

*Get Started Right Away!

Apply for Flexx Buy Program Financing Here: 

bottom of page