Informed Consent Form

Amy Redl

Emotion, Body, and Belief Code Practitioner

healingstartshere.amy@gmail.com

Telehealth Consent

I understand that Healing Starts Here LLC sessions are done by proxy. It is not a source or replacement of healthcare or medical/psychological advice, nor does it refute current medical advice or treatment by licensed professionals. I understand this practitioner is not licensed or authorized to give a diagnosis or prescribe treatment during the session.I understand the practitioner will not be working under her current registered nurse license, but under Emotion Code, Body Code and Belief Code certification which is without licensure. If medical care is needed, I shall seek care from a licensed professional.I understand all information from the session shall be sent to me and/or discussed with me per my selection of options and the decision to use that information belongs to me. I understand the practitioner does not take responsibility for any decisions made by me to use or discard the information.I understand imbalances will always be identified, assessed, and released remotely by proxy method (practitioner standing in for the client for releases) using only the practitioner by swiping a magnet over a portion of the practitioner's governing meridian a certain number of times. I receive and accept this service by this method. I understand muscle testing by the practitioner on the practitioner will facilitate and confirm findings as well as the release (or cancel out) the findings.I understand the information is not a recommendation from the practitioner, but a relaying of information from my subconscious mind during the session as the practitioner makes a connection with me and asks questions regarding imbalances or needs. I understand I must take responsibility for my own health, well-being, and assume all risks associated with this healing service.I understand I will be provided the results of the session via audio memo and/or typed transcript per my chosen preference(s).I understand after the completion of the session, I will enter a processing period to integrate the changes of the session which can result in a brief period of negative emotions or reactions such as fatigue, restless sleep, discomfort, blood pressure changes, emotional sensitivity, and other signs of healing. I understand symptoms, when experienced, are usually minor and resolve within a day or two. I understand the practitioner shall use prudence and safe practices taught within the certification to avoid heavy processing.I agree to waive any right to hold this practitioner liable for harm or perceived harm that may result from the remote services. I agree to indemnify this practitioner if I cause anyone else harm as a result of the services. I understand that Healing Starts Here LLC does not guarantee all sessions will be effective. Healing occurs at an unpredictable rate which is different for each person.I understand all client information will be stored on a private, business laptop and not shared with anyone else without my consent when possible. I understand there is no legal privilege for services and privacy may have to be violated if law mandates it. I understand this practitioner is a mandated reporter, which presents an exemption to confidentiality if there is a reasonable suspicion of child abuse, elder abuse, human trafficking, or imminent self-harm of the client.I understand that it is my responsibility to ensure privacy and security of communication to wherever I am located and however I am utilizing the service. It shall be my responsibility to ensure the control and management, including prohibition and restriction of use of any virtual assistant artificial intelligence (AI) such as Alexa or risk its use.I understand that I, my guardian, or my practitioner can discontinue my session for grounds which may not appear to be beneficial to me or whether it is deemed by the one calling for discontinuation reasonable.I understand that Healing Starts Here LLC is not an emergency service. In case of emergency, I shall contact 9-1-1 or any other emergency service provided by the government or any institution.I understand that there is no perfect security and transmission of information in any remote communication and potential risks are inevitable and which may arise through no fault of the practitioner.Other

By signing this form, I declare that I have had the opportunity to ask questions regarding the services that are available and within the scope of Healing Starts Here LLC, and the questions were answered to my satisfaction. In this regard, I hereby give my informed consent to the use of Healing Starts Here LLC healing services.

Age of Consent

I declare that I am of legal age and I hereby give my voluntary consent to this informed consentThe patient is below legal age and a guardian shall give consent on behalf of the child

Name of Patient

First NameLast Name

Date

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Name of Guardian

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