Yoga Therapy Intake Form

Name *
Name
Address
Address
Preferred method of communication
Yoga
How often to you practice?
What styles of yoga have you practiced?
Goals
What goals do you wish to accomplish through yoga therapy?
History
How do you rate your current level of activity
1- sedentary 5- extremely active
Describe your current workout/exercise:
If yes which type?
How do you sleep?
Be as descriptive as possible.
Please check the following that describe your eating patterns.
Do you have children?
Do you:
Do you use pain medication?
Spiritual Awareness
Physical and Mental Health History
Check all that apply
Please indicate whether you have been diagnosed with any of the following diseases or symptoms:
Emotional Trauma
I would be honored if you would share a little about your story if you have experienced emotional trauma of any kind.
Please check all that apply
If yes, please describe:
Please describe
Yoga Therapy and Lifestyle Goals
Sessions
I require an initial session that will last 1 1/2 hours. Follow up sessions will be 1 hour long. There is a required meeting of at least 4 times, consistently once a week. This is so we can make progress together and keep up the momentum. The cost is $75 for the initial session and $50 for the follow-up sessions. You can pay as you go or all at once.
Please Initial Below