PMA/Intake Forms

To prepare for your meeting with Tracey, please join the PMA Share Network free of charge and then fill out the intake form below. Thank you.

Step 1: Join the PMA Member Share Network

I look forward to making it possible for you and your family to have access to safe, effective options for your health. To enjoy the benefits of the Member Share Network you must read and agree with the Member Share Agreement.  You are electronically accepting the terms of this agreement by proceeding with member registration and a copy will be emailed to you by email after registration.

  • Practitioner Name: Tracey Middleton
  • Practitioner email address: tracey_middleton@verizon.net

Click here to register. You will be taken offsite to the PMA Member Registration page.

Step 2: Tracey’s Client Intake Form Online

You can also download a PDF version of Tracey’s Client Intake Form here: clientintakeform.pdf

Upon submitting this form, please email Tracey directly to alert her to your form submission: tracey_middleton@verizon.net


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  • By clicking "Yes" below, I hereby give Tracey Middleton permission to call my emergency contact #1, and if not available #2, if she and/or I deems it appropriate when extra support is needed and/or in case of an emergency.

  • I have been informed about the field of therapeutic practice that works with one or more aspects of the human energy system to bring about body-mind relief. In addition, I have been informed about where to find scientific studies that are confirming the value of these approaches for releasing trauma and anxiety, as well as increasing relaxation, reducing pain sensation, and enhancing a sense of well-being.
    I further understand that, because these methods are relatively new, the extent and breadth of their effectiveness, including benefits and risks, are not yet fully known.
  • All of the following may arise while working with Tracey Middleton:
    *Vivid or traumatic memories may fade. This could adversely impact my ability to provide legal testimony regarding a traumatic incident.
  • *Reactions may surface during a treatment session that neither Tracey Middleton nor I can fully anticipate, which may include the triggering of painful emotional and physical sensations and/or bring up additional unresolved memories.
  • *Emotional material may continue to surface after a treatment session and give indication of other issues and events that need to be addressed.
  • *Tracey Middleton may refer me to other practitioners who have specific skills to help with problem areas beyond her scope of practice, only once given consent by me to release my information.
  • *I will be learning personal self-care with my own energy system as part of the therapeutic process.
  • I have considered the above information before agreeing to receive energy therapy and have obtained additional information or professional advice I consider necessary to make an informed decision. I choose to participate in energy therapy of my own free will and know I have the right to cease using these methods at any time. I agree to take fully responsibility for my self-care by sharing any discomforts or questions I have with Tracey Middleton as quickly as possible.
    By clicking “Yes” below, I herby give my informed consent to work with Tracey Middleton using Energy Therapy approaches that she has been trained in.
  •   Yes I give my informed consent to work with Tracey Middleton using Energy Therapy approaches
      No I need more clarifying information before I agree to work with Tracey Middleton and request a meeting with her to address concerns about my informed consent

*Informed Consent adapted from the book Creating Healing Relationships by Dorothea Hover-Kramer.