Debra J. Macking, Licensed Massage Therapist


The below information is required to be filled out and sent via e-mail prior to your first Total Package 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: Total Package In-take 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 received massage before - how long ago?_____________________ Have you had Energy Work done before - what forms, how often, how was your experience: _____________________________________________________ Required 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 TotalPackage: Your massage therapist has been trained here in the state of Florida and is a Licensed Massage Therapist. Further experience with Energy Work and Meditation is in a variety of forms and styles. Meditational Massage is a unqiue experience that can and often does incorporate deep tissue massage, relaxation massage, healing touch energy work, and a verbal guided meditation often aimed at bringing you to a sense of comfort, safety, and relaxation (this can vary with goals of work). During the massage you will be draped with a sheet. At any time during the massage either you or the therapist may stop the session. Please alert the therapist if the pressure of the massage is too much or not enough also inform the therapist of any areas that you prefer not to have worked. Areas that will NOT be worked on either male or female clients, is the genitalia, by requesting that this area be worked is wrong and grounds for the massage to end at that time with full payment still due. 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 Total Package 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: Total Package In-take 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 received massage before - how long ago?_____________________

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

Required 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 TotalPackage:

Your massage therapist has been trained here in the state of Florida and is a Licensed Massage Therapist. Further experience with Energy Work and Meditation is in a variety of forms and styles.

Meditational Massage is a unqiue experience that can and often does incorporate deep tissue massage, relaxation massage, healing touch energy work, and a verbal guided meditation often aimed at bringing you to a sense of comfort, safety, and relaxation (this can vary with goals of work).
During the massage you will be draped with a sheet. At any time during the massage either you or the therapist may stop the session.
Please alert the therapist if the pressure of the massage is too much or not enough also inform the therapist of any areas that you prefer not to have worked. Areas that will NOT be worked on either male or female clients, is the genitalia, by requesting that this area be worked is wrong and grounds for the massage to end at that time with full payment still due.

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!