Trauma Sensitive - Assessment Intake and Consent
In order to provide as safe and supportive experience as possible I’d like to ask you some questions.

All information is kept in the strictest confidence.

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Date
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Name
Do you have any preferred pronouns?
Mobile
Email
Please provide details for an emergency contact. This might be your GP, therapist, family member or a friend.
Emergency contact name:
Emergency contact phone number:
Emergency contact mail:
Emergency contact relationship to you:
General Physical Health Background
How would you describe some of the challenges you face on a daily basis? (symptoms, moods, etc.)
Are you on any medications that you feel it would be useful for me to know about? If yes, please provide details.
Are you currently engaging in behaviours that worry you or those around you? This might include your use of non/prescription medication, food, alcohol or sex. It might also include behaviours such as cutting or burning.
Do you have any physical injuries or pre-existing medical conditions? Please describe.
Have you ever had surgery? If yes, when and what kind?
Are there any movements/shapes which cause you physical discomfort or pain? Please describe.
Do you suffer from back pain? If yes, please provide details.
Has your doctor ever said your blood pressure is too high (above 140 / 90) or low? Please specify.
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Do you suffer from sleep issues? Either difficulty falling to sleep, or staying asleep?
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Are you pregnant or postpartum? If yes, please specify which week.
Support, Stability & Safety:  It is important that you feel relatively stable and safe in your life whilst you explore the yoga practice.  For this reason I’d like to ask the following questions:
If you’re having a challenging day do you have someone you can reach out to for support?
Do you have a safe home to live in?
Are you currently in any significant relationships that make you feel unsafe?
Trauma Details: Feel free to answer the following questions. You are also welcome to leave this section blank.
Are you or your therapist using any official diagnostic label to frame your experiences? Eg. PTSD, anxiety, depression, Complex PTSD, Dissociative Identity Disorder etc.
Without including the specifics of your experiences, how would you describe your general trauma category? Eg. domestic violence, childhood abuse, sexual assault/abuse, war or military related, or neglect.
Have you needed hospitalisation for your trauma related symptoms in the past 6 months?
Movement Information
Do you practice any physical exercise on a regular basis?
Have you ever practiced yoga before?
Are there any yoga shapes or ways of breathing that you have found triggering & that you would rather avoid?
Are there any yoga shapes or ways of breathing that you have found useful & that you would like to explore?
Is there anything about coming to trauma sensitive yoga sessions that worries you & that you’d like me to be aware of?
Is there anything that hasn’t been asked that you would like me to know?
Do you know of any other triggers like words/ smells/ clothes/ my eyes closed/ your eyes closed you may find triggering?
Do you find making choices difficult or noticing your body triggering?
Access To Therapy.  In this yoga practice we explore ‘having a body’, for example noticing muscles lengthening or shortening, noticing shifts in pressure. ‘Having a body’ can be challenging and emotional, and so it is important that you can access a therapist. Please confirm the following:
Are you currently receiving psycological therapy?
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How long have you been working with your therapist? Less than 4-6 months?
Is your therapist aware that you are participating in the yoga program?

I am happy to be placed on the mailing list to contact me about sessions or other information?
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Consent: Just like any form of physical activity, yoga carries a risk of injury and I agree to take precautions and responsibility for my own actions. I have, to the best of my ability, disclosed any necessary information about prior injuries, pre-existing medical conditions and personal history that may be relevant to my safety and the safety of others. I understand that Trauma Center, Trauma Sensitive Yoga is an adjunctive practice and that participants are required to have access to established therapy within which they can reflect upon their trauma history. I am aware that Facilitators of TCTSY do not provide psychotherapy during the course of the yoga session. I understand that TCTSY is not considered useful if I have needed a hospitalisation within the last 6 months, for my trauma related experiences. I consent to allow the above information to be collected, stored & used only in so far as it is necessary for Kathryn Fa to offer me TCTSY sessions. I understand that no information about me will be shared with any third party unless Kathryn Fa judges an exception to confidentiality has been met. A TCTSY Facilitator has the right to deny or terminate service to any person who may represent a threat to the safety of themselves and/or others, including the Facilitator.
Date:
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Signature Of Yoga Student. Please type your name below to acknowledge your consent:
Experiences of psychological trauma profoundly change our relationship with our body. TCTSY is built by trauma survivors, for trauma survivors.  Trauma-informed movement complements psychological therapy to help survivors safely re-connect to their body so that they may engage more fully with their life.
Yoga Atelier .  kathryn@yogaatelier.co.uk
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