We want to make sure you remain happy & healthy.

Please complete the consent form specific to your requets.

Medical Questionnaire

Please fill out the following form prior to your FIRST VISIT

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

First Name

Date of Birth

Last Name

Employment Status or Student? Please list:

Address

Phone

Emergency Contact

Physician Name

Therapist Name

Emergency Contact Phone

Physician Phone

Therapist Phone

Current Medications and Supplements

Number of Children & Ages

Pets?

Have you been hospitalized in the last 12 months?

Yes

Are you currently diagnosed with a medical condition, illness, or injury?

Yes

Do you have Diabetes? (please eat 1 hour before session.)

Yes

Do you have a diagnosis of Depression?

Yes

Do you have a diagnosis of Anxiety?

Yes

Do you think you have depression and/or anxiety?

Yes

Do you have any other mental health diagnoses?

Yes

If you answered yes to any question, please list conditions:

Are you pregnant or nursing?

Yes

If you are pregnant, How many weeks? (must be past 13 weeks gestation for Massage. NO reflexology if pregnant):

Do you drink?

Yes

Do you smoke or vape?

Yes

Ingest THC or CBD?

Yes

Have you ever had a Reiki Session or Energy Healing Session?

Yes

If you answered yes to any question, please list/explain:

What is your PHYSICAL pain level from 0-10 with 10 being the worst?

What is your EMOTIONAL pain level from 0-10 with 10 being the worst?

What is your STRESS level from 0-10 with 10 being the worst?

What is your level of HAPPINESS from 0-10 with 10 being complete happiness?

If physical, where is your pain? For how long?

Please list any traumatic or life-threatening events that you would like help with and when they happened:

What spiritual practices do you engage in (e.g., meditation, prayer, church, yoga, Tai Chi, etc) ?

What alternative health therapies have you experienced (e.g., Reiki, Acupuncture, Healing Touch, Massage, Reflexology, etc.)

What other holistic services are you interested in at Listening Hands LLC?

What are your expectations for this session?

How did you find Listening Hands LLC?

Do you have any additional comments or questions to be answered before we begin your session?

I declare that the info I’ve provided is accurate & complete

Completed by parent or guardian

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 understand that any changes to my appointment must be made within 48 hours prior to the appointment or I will be charged 50% of the appointment. No shows will forfeit 100% of the appointment amount. I also understand that I will be charged for Life Purpose Coaching/Spiritual Counseling @ $125/hr if initial discussion, prior to hands-on treatment is greater than 15 mins. I consent to the service.

Subscribe to mailing list via email & text appointment reminders.

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!

*Thank you!
Your form has been submitted. All information is confidential.
Please scroll down and complete the Health Declaration.

Now Click Here for Health Screen

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.

Cardholder Name (as shown on card):

Middle

Last Name

Last 4 digits

Cardholder ZIP code (from credit card billing address)

Expiration Date

authorize Listening Hands LLC to charge my credit card for agreed upon purchases.

Please sign

I understand that my information will be saved to file future transactions on my account.

Please sign

I understand that any changes to my appointment must be made within 48 hours before the appointment or I will be charged 50% of the appointment.

Please sign

If I no show, I will be charged the full amount of the appointment.

Date:

Thank you for Submitting!

Please present card in office.

We want to make sure you remain happy & healthy.

Medical Questionnaire

Please Read & Sign Next Line

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

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!

*Thank you!
Your form has been submitted. All information is confidential.
Please scroll down and complete the Health Declaration.

Credit Card Authorization Form

APPOINTMENT ONLY

We have a cashless system.

We accept all major credit/debit cards & also payment apps such as Paypal.
You can also select Sezzle at online check out to Buy Now & Pay Later for services & products.

We do not accept any form of insurance.

Disclaimer

We want to make sure you remain happy & healthy.

Medical Questionnaire

Please Read & Sign Next Line

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

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!

*Thank you! Your form has been submitted. All information is confidential. Please scroll down and complete the Health Declaration.

Credit Card Authorization Form

*Thank you!
Your form has been submitted. All information is confidential.
Please scroll down and complete the Health Declaration.