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Healing Client Introduction Form
Healing Client Introduction Form
Step 1 of 10
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
French Southern Territories
Heard and McDonald Islands
Isle of Man
Lao People's Democratic Republic
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Svalbard and Jan Mayen Islands
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
US Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Date of Birth:
Emergency Contact Name:
Emergency Contact Phone:
Is your living situation a source of comfort to you?
Please provide a little more information for me:
What is your reason for seeking a Healing session?
Do you have experience with energy medicine (Acupuncture, Healing Touch, Craniosacral Therapy, Reiki, etc.) or other vibrational therapies?
If yes, please provide a list of what types of energy medicine you have experience with or a list of practitioners you have previously worked with.
Please describe any physical concerns that you would like to focus on or have me know about.
Please check the primary reasons for seeking out energy and intuitive support: (check all of those that apply):
Grounding and centering
Relaxation and self-care
Cancer Treatment Support
Major Life Change
Past Life or Future Life Information
Cosmic or Planetary Information
Please list sources of Relaxation / Self-Care:
In the following questions, if you feel comfortable, please share a little about your alignment to a specific religion or Spiritual philosophy*
*These questions help me to align our work in a context that feels comfortable and supportive to you.
Is your religion or Spiritual belief a sense of comfort for you?
Is there a specific way that you like to connect to your spiritual support?
If you use a specific word/name for a higher power, please share that with me. (Examples: God, Universe, Great Spirit, Christ, Allah)
What do you say "no" to in your life?
What do you wish you said "no" to in your life? (Or wish you said "no" more often to?)
What, if anything, do you dream you could do in life?
In general, when you think of your life, do you feel safe?
If "sometimes" or "no" and you feel comfortable doing so, please share a little more with me about your sense of safety.
In general, when you think of yourself, do you feel like a “whole” being?
If "sometimes" or "no" and you feel comfortable doing so, please share a little more with me about your sense of wholeness.
What is your greatest strength?
Do you know of a belief belief that appears in your life that is no longer serving you? (Some examples are: I’m not good enough; I’m not OK; I don’t want to be here; I don’t belong; I am unlovable)
Do you currently feel overwhelmed in your life?
If yes, is there a particular area of your life that feels overwhelming?
Do you feel like there are (or may be) any ancestral or familial patterns are affecting you in your life?
If yes, please share what you think or know:
If you have a specific health item that you’d like to focus on during your healing session?
Do you have any idea what might be the source of this item?
Is there anything else that you would like for me to know before our first session?
Amelia Vogler (MS, HTCP/I) uses Healing Touch, hands-on or hands-off energy therapies, energetic craniosacral therapy, energetic reflexology, tuning forks, gemstones, flower essences, and therapeutic-grade essential oils (aromatherapy) to help attune and balance your energy system. Amelia also receive intuitive information for healing work, intuitive consulting, and professional mentoring. All of these therapies are a form of vibrational healing. I understand that these therapies are gentle, integrative energy-based approaches to health and healing that can assist my body in its natural ability to heal. I fully acknowledge and understand these therapies are performed by contact and/or non-contact touch. I understand that these therapies are integrative therapies not intended to replace any currently prescribed medical treatments as ordered by my physicians nor any other medical care that I have been advised to seek by them. I understand that Amelia Vogler does not hold a license to practice medicine in the state of North Carolina. I have been encouraged to consult a licensed medical practitioner for medical evaluation and treatment. I agree to be an active participant in my healing process and to take ownership over my own healing journey. I understand that intuitive coaching is not a substitute for professional counseling. I understand that any session notes are confidential and that my experiences in these sessions are confidential and subject to the usual exceptions governed by State or Federal laws and regulations. I understand that there is a 48 hour cancellation policy and if that policy is not adhered to then a $50 missed appointment fee is charged. I give my consent to receive Healing Touch, energetic reflexology, tuning fork therapy, gemstone therapy, aromatherapy, flower essences, intuitive coaching, professional mentoring from Amelia Vogler - MS, HTCP/I, Mentor. This form is an important legal document. It explains the assumption of any and all risks in deciding to follow the advice or insight from intuitive consultant Amelia Vogler, who operates as an advising consultant through The Healing Space LLC. It is critical that you read and understand it completely. After you have done so, please via electronic signature. Waiver, Informed Consent, and Covenant Not to Sue I hereby acknowledge I have volunteered to participate in a paid or unpaid session, class, workshop, service or program with Amelia Vogler or The Healing Space, LLC to include, but also may not be limited to, any and all services provided, such as energy healing, vibrational medicine, intuitive coaching, guidance, readings, charts, classes and workshop attendance. In consideration of the The Healing Space, LLC agreement to instruct, assist, advise, or train me, I do here and forever release and discharge and hereby hold harmless the The Healing Space and its respective agents, heirs, assigns, contractors, and employees from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in a session or purchase or any program WITHOUT LIMITATION, WHICH MAY OCCUR AS A RESULT OF following advice tendered and released or training rendered or use of facilities during a session or event. I recognize that in no way does any member of The Healing Space, LLC provide legal, medical, or therapeutic advice and it is my responsibility to secure such advisement. I acknowledge and agree that I assume the risks associated with any and all activities, offerings, services, classes and/or programs in which I participate. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from any insight, guidance or program. I understand that results are individual and may vary. I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY SIGNING THIS DOCUMENT, I AM WAIVING ANY RIGHT I OR MY SUCCESSORS MIGHT HAVE TO BRING A LEGAL ACTION OR ASSERT A CLAIM AGAINST THE HEALING SPACE, LLC FOR THEIR NEGLIGENCE OR THAT OF THEIR EMPLOYEES, AGENTS, OR CONTRACTORS.
I have read and agree to the Consent to Treat and Waiver Release and Assumption of Risk clauses.
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