Maggie’s Client Intake Form

Center for Advanced Energy Medicine

Maggie Begley Energetic Evaluation & Bodywork 

Today’s Date:________________

Name:___________________________________________________

Full Mailing Address:__________________________________________

Home Phone: ____________________________________

Work Phone: _____________________________________

Cell Phone: ______________________________________

Email Address:_______________________________________________

Emergency Contact (name/ph#):_______________________________________

Date of Birth:________________________________________________

Occupation:_________________________________________________

Referred by:_________________________________________________

What is your primary reason for coming today?

____________________________________________________________

Have you had bodywork before, and if so which modalities?

____________________________________________________________

Any additional health problems, allergies/sensitivities, injuries, surgeries, or other concerns that I should be aware of, such as areas to avoid:

___________________________________________________________________

___________________________________________________________________

*** When coming to our office we request that you please refrain from your use of scented products, natural or otherwise, as much as possible. Thank you for your consideration.

*** Permission & Disclaimer:  

I may consult with my colleague and mentor, Dr. Richard Metz, about your treatment/condition if I think that it might be useful or necessary.

This therapy is not a substitute for conventional allopathic medical care. For diagnosis, monitoring and treatment of medical conditions, please consult your physician.

*** Please sign and date here to acknowledge your understanding and approval of the above statements: 

____________________________________________________________________

I appreciate you being here and I look forward to working with you on your healing journey. 🙂

 

(Last edited 11/06/13).