INTAKE FORM for Atlas Balancing, Energy Medicine
Confidential Initial Intake form

Jody Wallace, LMT, Energy Medicine Practitioner.               N.Y. state License # 009721-01
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Name
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Date: *
Birth date:
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Address *
Phone number *
Occupation:
What goals and results do you want from your session?
HEALTH CONCERNS; What brings you here for the session:
Health History Intake:
Spinal issues, neck injuries, please specify:
Surgeries;
Medications:
Stress reduction, exercise, hobbies:
Did someone refer you?
DISCLAIMER: Atlas Balancing/Energy Medicine is not a medical therapy, does not involve a diagnostic routine, nor is it chiropractic or osteopathic manipulation. No diseases are treated specifically. The sole function of these sessions is to support the SELF HEALING capacities of the person, physically and psychologically, as well as for working on the energetic levels. The protocol uses sound, intention and light touch, (but can also be done in silence and is effective in a distance session). Please continue any ongoing medical treatments and care. No promises of cure have been made. I have been informed about possible physical reactions that I might experience during the self healing process and which may involve muscular tensions, nerve irritations, fatigue, or modification for the jaw joint and teeth positioning as the body unwinds. Cost of Atlas Balancing: $250.00. Cost of Body Balancing: $195.00. Cost of Energy Medicine Sessions: Initial intake appointment, $100.00. Subsequent sessions $80.00 first hour, (additional  time at $60.00/hour). *
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