First Appointment Intake Form
Please complete this form to the best of your ability prior to your appointment with Jaimie.

Your answers will be saved on a secure HIPAA compliant drive.

This intake form can take up to 15 minutes to fill out. Some answers are required and will have * next to them.

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Full Name *
Electronic Signature: I agree that checking the following box confirms that the above-named person completed this form. *
Required
I agree and consent to Jaimie Perkunas, DPT, e-RYT, C-IAYT & Yoga is Therapy LLC to perform yoga therapy treatment and care which includes but is not limited to: self massage, poses and exercises, postural awareness and yogic breathing. I am aware that there are risks involved in physical training. I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or loss that may result from performing in this yoga program. *
Required
I release Yoga Is Therapy LLC & Rooted Integrative Wellness Center (located at 1600 N. Tucson Blvd. Suite 100, Tucson, AZ 85716) its employees & contractors from any & all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this yoga program. *
Required
I understand Telehealth is an option for appointments, which includes video and audio communication. Possible risks of Telehealth include information transmitted may not be sufficient (e.g. poor resolution of images) by deficiencies/failures of the equipment, and in very rare instances, security protocols could fail, causing a breach of the privacy. *
Required
I understand that Yoga is Therapy’s services are categorized as wellness and preventative services and are not covered by health insurance companies or Medicare. *
Required
I understand Jaimie will be taking pictures for me in poses to help create an exercises handout. These photos will be kept private. Jaimie will only share patient information with other providers with verbal or written permission from client. *
Required
I understand that Yoga is Therapy LLC has a minimum of a 48 hour cancellation policy and details of the cancellation policy are available in confirmation emails, email reminders, and on Yoga is Therapy website. I understand that if I am late for my appointment, my visit will end at the scheduled time and therefore be shortened. Please type full name below to acknowledge this information: *
I understand that Yoga is Therapy may send SMS/Text communications for appointments *
Required
I would like to receive SMS/text communications at this number (cell phone numbers only) *
My preferred method(s) of contact for appointment updates? *
Required
My mailing address is *
My emergency contact is:  (Provide name and phone number) *
My date of birth is *
My yoga experience is *
I would like to discuss, work on, or learn *
The things that I have tried that HAVE WORKED are *
The things that I have tried that HAVE NOT WORKED are
The feelings or emotions that arise when things don't work are
My general health is *
The exercise I enjoy is
My exercise program is (frequency/duration)
The practitioners I have worked with in the recent past or currently are
I have experienced the following: *
Required
I have a history of the following surgeries: *
Required
My primary care doctor is
I have a counselor/therapist (if yes, please include name)
My stress level in the last 6 months has been *
My long term stress level has been *
I feel stressed about *
I manage my stress with *
I feel good about *
I expect to recover in (% of recovery and time frame) *
Additional information I would like to share is
I heard about Yoga is Therapy/Jaimie Perkunas from *
I would like to be added to cancellation list *
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