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Caregiver Application

Healing Hands for Helping Hearts provides therapeutic massage services at an affordable rate and encourages caregivers to participate regularly. An application is required and a referral is necessary from either a case manager or a physician. This information will not be shared and will be kept confidential. An appointment requires fifty dollars for a one hour treatment session and the appointments will be scheduled with a therapist at their private office space.
It is highly suggested this form be filled out on a computer as opposed to a mobile device.

(999) 999-9999
(999) 999-9999
(e.g., parent, child, etc.)

Upon completion and submission of this application you will be directed to the PayPal site to select your form of payment and complete this application process.

You do not need a PayPal account to provide payment. You may use a credit card or if you have a PayPal account you may use it for your payment.

When you've completed the payment process you'll be returned to the home page of this site.
Thank you!

You may pay at the time of your visit. Please be have your credit card, a personal check or cash with you when you arrive.

Thank you!

Please complete and submit this application to enquire about a gift certificate.

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Healing Hands will contact applicants within 5 business days for initial consultation. We look forward to being of service.