Debra J. Macking, Licensed Massage Therapist


The below information is required to be filled out and sent via e-mail prior to your first meditation. 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: Meditation 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 daily?_______________ What forms and styles of meditation have you tried?______________________ ______________________________________________________________ How would you describe what meditation is to you?_______________________ _________________________________________ Optional Current Favorites List: 1. Place/scene of comfort & safety:_______________ 2. Scent for that place/scene:___________________ 3. Time of Day:__________________ 4. Time of Year:_________________ 5. Dream mode of transportation:________________ 6. Favorite/important animal or symbol in your life:_________________ 7. 2-3 Things causing stress:___________________________________ _________________________________________________________ 8. Spiritual/Religious/Philosophical systems you align with:___________ _________________________________________________________ Where did you hear about us? _______________________________ About Your Meditation: Your meditation guide works with a variety of forms and styles of meditation. The meditation will take approximately 45minutes with a 15minute discussion before to discuss styles and help find what will work best for you. Guided meditation is an invitation to explore many areas of your life so that a sense of peace, acknowledgement, understanding, and/or relaxtion will be found. The nature of this work incorporates energy work. If you have any questions please discuss them prior to the meditation. 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 meditation.
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: Meditation 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 daily?_______________

What forms and styles of meditation have you tried?______________________

______________________________________________________________

How would you describe what meditation is to you?_______________________

_________________________________________

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

Where did you hear about us? _______________________________

About Your Meditation:

Your meditation guide works with a variety of forms and styles of meditation.
The meditation will take approximately 45minutes with a 15minute discussion before to discuss styles and help find what will work best for you.

Guided meditation is an invitation to explore many areas of your life so that a sense of peace, acknowledgement, understanding, and/or relaxtion will be found. The nature of this work incorporates energy work. If you have any questions please discuss them prior to the meditation.

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!