Please fill out the following form prior to your FIRST VISIT
to help us understand your needs. This form is NECESSARY for treatment.
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).
Your form has been submitted. All information is confidential.
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