Debra J. Macking, Licensed Massage Therapist


The below information is required to be filled out and sent via e-mail prior to your first Energy Work 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: Energy Work Standard Intake 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 INJURIES, SURGERIES, AND MEDICAL CONDITIONS YOU HAVE HAD IN THE LAST 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:_________________ What areas are you experiencing discomfort? ___________________ Do you meditate - at what frequency?_______________ Have you had Energy Work done before - what forms, how often, how was your experience: _____________________________________________________ _______________________________________________________________ Optional Current Favorites List: 1. Place/scene of comfort & safety:_______________ 2. Scent for that place/scene:___________________ 3. Time of Day:__________________ 4. Time of Year:_________________ 6. Favorite/important animal or symbol in your life:_________________ 7. 2-3 areas of stress currently in your life:_______________________ _________________________________________________________ 8. Spiritual/Religious/Philosophical systems you align with:___________ _________________________________________________________ Where did you hear about us? _______________________________ About Your Energy Work: Your Energy Work guide has a variety of forms and styles available to assist you. Energy Work will vary in form and length of time. A 15minute discussion before to discuss styles and help find what will work best for you is designed to make the most of the experience. Energy Work is an invitation to explore many areas of your life so that a sense of peace, renewal, connection, and/or relaxtion will be found. If you have any questions please ask! 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 Energy Work 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: Energy Work Standard Intake 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 INJURIES, SURGERIES, AND MEDICAL CONDITIONS YOU HAVE HAD IN THE LAST 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:_________________

What areas are you experiencing discomfort? ___________________

Do you meditate - at what frequency?_______________

Have you had Energy Work done before - what forms, how often, how was your experience: _____________________________________________________
_______________________________________________________________

Optional Current Favorites List:
1. Place/scene of comfort & safety:_______________
2. Scent for that place/scene:___________________
3. Time of Day:__________________
4. Time of Year:_________________
6. Favorite/important animal or symbol in your life:_________________
7. 2-3 areas of stress currently in your life:_______________________
_________________________________________________________
8. Spiritual/Religious/Philosophical systems you align with:___________
_________________________________________________________

Where did you hear about us? _______________________________

About Your Energy Work:

Your Energy Work guide has a variety of forms and styles available to assist you.
Energy Work will vary in form and length of time. A 15minute discussion before to discuss styles and help find what will work best for you is designed to make the most of the experience.

Energy Work is an invitation to explore many areas of your life so that a sense of peace, renewal, connection, and/or relaxtion will be found. If you have any questions please ask!

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!