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).

2 Responses to Maggie’s Client Intake Form

  1. Judy says:

    I am interested in adding a client intake form to my WordPress website and was hoping you would share with me the app name you used to create yours. I’d appreciate your help.

    Best.

    Judy Johnston, CHt, PLR
    That’s Life Hypnosis
    Matthews, NC

    Like

    • Hello Judy,
      I didn’t use an app, I just cut and pasted from the word processing file I had created long ago. I didn’t even know there was an app for that. If you find a good one, let me know.
      Thanks, Maggie

      Like

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