Debra J. Macking, Licensed Massage Therapist


The below information is required to be filled out and sent via e-mail prior to your first Life Guide Session. Copy and paste the information into a .doc/.rtf/.txt file or simply into the body of an e-mail and send it to achievinglife@gmail.com with subject: Life Guide Form. We are in the process of creating a form to send your responses via the site Note that at the appointment you will be verifying information. NAME: ______________________________________ ADDRESS: ___________________________________ PHONE #:____________ ALT. PH #: ____________ DATE OF BIRTH: __________ LIST ANY MEDICAL CONDITIONS and MAJFOR LIFE CHANGES BOTH POSITIVE AND NEGATIVE THAT YOU HAVE HAD IN THE PAST 12 MONTHS: ___________________ __________________________________________________________________ Do you smoke? _____ How often? ______ Do you drink alcohol? ____ How often? ______ How much water do you drink on average each day? _________ Do you exercise or workout - at what frequency:_________________ Do you meditate - at what frequency?_______________ Are you part of any alternative or complementary therapy program - what form? ________________________________________________________________ Have you or are you currently working with any other Life Coaches, Guides, or Counselors? What for and how is that experience going:_________________________________ ___________________________________________________________________ Is there a Spiritual/Religious/Philosophical systems you align with:___________ _________________________________________________________ Where did you hear about us? _______________________________ About Your Life Guide Work: Your Guide has a variety of academic and real life experiences that can work to guide you along a path towards achieving a fuller and more satisfying life. Based on the form of work being done sensitive issues may arise, please be aware that your life guide may not be a licensed counselor and is not a medical professional. Life Guides are interested in your well-being and will work to guide you to those who can assist you as needed. I HAVE READ THE ABOVE SATEMENT AND AGREE TO ABIDE BY IT and HAVE COMPLETED THE ABOVE FORM TO THE BEST OF MY ABILITY. ____________________________________________________ Client Signature and Date
~ Thank You ~ Always remember: Live, Love, Laugh, and Learn! Site Design by David Michaels and Debra J. Macking. Copyright © 2008. All rights reserved. Achieving Life Hand Logo © 1998 Walter Ramsey. Used with permission.

The below information is required to be filled out
and sent via e-mail prior to your first Life Guide Session.
Copy and paste the information into a .doc/.rtf/.txt file
or simply into the body of an e-mail and send it to
achievinglife@gmail.com
with subject: Life Guide Form.
**We are in the process of creating a form to send your responses via the site**
Note that at the appointment you will be verifying information.

NAME: ______________________________________

ADDRESS: ___________________________________

PHONE #:____________
ALT. PH #: ____________
DATE OF BIRTH: __________

LIST ANY MEDICAL CONDITIONS and MAJFOR LIFE CHANGES BOTH POSITIVE AND NEGATIVE THAT YOU HAVE HAD IN THE PAST 12 MONTHS: ___________________ __________________________________________________________________

Do you smoke? _____ How often? ______

Do you drink alcohol? ____ How often? ______

How much water do you drink on average each day? _________

Do you exercise or workout - at what frequency:_________________

Do you meditate - at what frequency?_______________

Are you part of any alternative or complementary therapy program - what form? ________________________________________________________________

Have you or are you currently working with any other Life Coaches, Guides, or Counselors? What for and how is that experience going:_________________________________ ___________________________________________________________________

Is there a Spiritual/Religious/Philosophical systems you align with:___________
_________________________________________________________

Where did you hear about us? _______________________________

About Your Life Guide Work:

Your Guide has a variety of academic and real life experiences that can work to guide you along a path towards achieving a fuller and more satisfying life. Based on the form of work being done sensitive issues may arise, please be aware that your life guide may not be a licensed counselor and is not a medical professional. Life Guides are interested in your well-being and will work to guide you to those who can assist you as needed.

I HAVE READ THE ABOVE SATEMENT AND AGREE TO ABIDE BY IT and HAVE COMPLETED THE ABOVE FORM TO THE BEST OF MY ABILITY.

____________________________________________________
Client Signature and Date

~ Thank You ~
Always remember: Live, Love, Laugh, and Learn!