Maggie Begley Energetic Evaluation & Bodywork
Today’s Date:________________
Name:___________________________________________________
Full Mailing Address:__________________________________________
Home phone #:______________________________________________
Work #:___________________________________________________
Cell / Text #:________________________________________________
Email Address:_______________________________________________
Emergency Contact (name/ph#):______________________________________
Date of Birth:________________________________________________
Occupation:_________________________________________________
Relationship Status:____________________________________________
# of Children:________________________________________________
Referred by:_________________________________________________
Have you had bodywork before, and if so which modalities?__________________________________________________
Please answer only if you are comfortable sharing:
What is your primary reason for coming today?______________________________________________________
What life issue is challenging you the most right now? _______________________________________________________
How would you like to see this resolve, or come to fruition?_________________________________________________________________
What do you think might be standing in your way, if anything?_____________________________________________________
Any additional health problems, injuries, surgeries, or other concerns that I should be aware of, such as areas to avoid?______________________________________________________________
Medications/supplementation you are taking?_______________________________________________________
Briefly describe your daily diet: _________________________________________________________
________________________________________________________________
How would you rate the following on a scale of 1 – 10 (1 being worst, 10 being best): Stress Levels?______ Sleeping Habits? ______ Eating Habits? _______ Addictions? ______ Love Life? ______ Elimination? ______ Career/Job Satisfaction? ______ Physical Health?______ Psychological Well-Being?______
I may find it helpful or necessary to consult with my colleague and mentor, Dr. Richard Metz, about your treatment/condition if I feel it is necessary.
Disclaimer: This therapy is not a substitute for conventional allopathic medical care. For diagnosis, monitoring and treatment of medical conditions, please consult your allopathic physician.
Remember, that even with Energy Therapy, you are the one who is ultimately responsible for the decisions you make. You have the power, whether you want it or not! 
Please sign and date here to acknowledge your understanding and approval of the above statements: ____________________________________________________________________
Today’s Session:
Energetic evaluation consultations and/or bodywork will help support your body’s own healing process by unblocking stuck energy and allowing it to flow more freely. Notice and acknowledge the thoughts, memories, visual impressions, emotions or physical sensations, if any, that may be released during this process — in our discussion, on the table, or even within days following. This insight into yourself will help you get the most from the session. Your comfort is very important to me. I am accustomed to working with chronically/terminally ill, and sensitive folks. I am one myself. (When coming to our office please refrain from wearing scented products, natural or otherwise, as much as possible. Thank you for your consideration.) So please don’t hesitate to let me know if we need to make any adjustments, at any time, for any reason during your session and I will do my best to remedy the situation on your behalf.
What You Can Do:
Everything is Energy: Be aware of the thoughts, emotions, food, drugs/supplements, music, exercise, work, fun, sensuality, nurturing, sleep, and relationships, etc., that you partake in and/or expose yourself to. We can shift our energy, for good or for bad, by engaging in any thought, emotion, physical activity, behavior, and/or interaction, be it internal or external. Bodywork is just one way to help de-stress and keep in balance. Other forms of self-care are equally important. Strangely enough, we all seem to need frequent reminders to pay attention to the basics of nurturing ourselves: breathe deeply, eat well, sleep enough, exercise and keep hydrated! Give yourself permission to be quiet, to be playful, to rest, relax and have some fun. Rest and relaxation is an important counter-part of productivity and maintaining balance. We all need to do the best we can to support ourselves and one another in positive ways every day, with the simple pleasures, and every little bit helps!
We are our own best guides when we relax, reconnect and trust our intuitive selves. All answers come in silence, if we take the time to listen.
© 2003, 2011 by Maggie Begley
“Up to the Twentieth Century, reality was everything humans could touch, smell, see, and hear. Since the initial publication of the chart of the electromagnetic spectrum, humans have learned that what they can touch, smell, see, and hear is less than one–millionth of reality.” — Albert Einstein
(Last edited 11/11/11).
