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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. 

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.

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

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Thank you for Submitting!

Please present card in office.

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