Trauma Sensitive Yoga - Intake Form
For Lead Provider:
Please complete this form with your client's consent so we know how best to support them during our 8 week course together. All information is confidential and we greatly appreciate your trust and transparency during this process. 

Once enrolled - Rachael Mason will reach out to client for onboarding call to finalise suitability.

How to request approval from ACC:
32 x SCGW (Trauma Sensitive Yoga) + 1 x SCGT2 (Group Triage)

Supplier: CARE Waitakere Trust
Vendor ID: G06930

Any questions or extra support, contact hello@kanukayoga.co.nz

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Where is the preferred location & time for client's TSY course? *
Client's full name (including preferred pronouns) *
Street Address     *
Phone Number *
Email *
Date of Birth *
MM
/
DD
/
YYYY
Lead Provider Name *
Lead Provider's Email Address *
Lead Provider's Phone Number *
How long has the client been engaged in therapy with you? *
Does the client have an accepted claim?  (Please note that your client needs an accepted claim in order to attend this group) *
ACC Claim No *
Mental health diagnosis covered by ACC *
Is there any current risk or safety concern for this client? *
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