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Body Image, Yoga and Mindfulness Group for Teen Girls
Please complete this form to express interest in our upcoming Body Image, Yoga and Mindfulness group for teen girls. We will contact you with more details and to set up a brief intake soon.
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Email
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Your email
Full Name of Participant (First and Last)
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Your answer
Age of Participant
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Your answer
Name of person completing this form (if not the participant)
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Your answer
Relationship to participant
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Provider (i.e. therapist, dietitian, doctor, etc.)
Parent or guardian
Prospective participant
Age of prospective participant?
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Your answer
What would you like to get out of this group?
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Connect with others
Feel empowered
Feel better about self-image
Learn how to cope with negative body image thoughts as they arrive
Take action around harmful messaging about bodies
Engage in movement that helps me feel good in my body
Learn mindfulness, meditation and breathing techniques
Other:
Required
Do you if have any experience with Yoga?
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Yes
No
If "Yes", describe your experience:
Your answer
Do you have/have you had an eating disorder?
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Yes
No
If "Yes", please give a brief description of where you are in your recovery process:
Your answer
If you are in eating disorder recovery, please list your current members or your treatment team
Your answer
Are you cleared by your Medical Doctor to participate in a 45 minute yoga class?
Yes
No
Unsure
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How would you describe your current relationship with food?
Your answer
Are you currently engaging in physical activity? If yes, what type and how often? How would you describe your relationship to exercise?
Your answer
How you do currently cope with stress?
Your answer
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