4. Is it okay to leave a private voice message? * Mark only one oval.
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5. Mailing Address
Your answer
6. City
Your answer
7. State
Your answer
8. Zip Code
Your answer
9. Pronouns
10. What is the best way to contact you?
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11. Birthdate
MM
/
DD
/
YYYY
12. Occupation
Your answer
13. Marital Status
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14. Do you have children?
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15. Do your children live at home?
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16. Have you ever participated in an Apanii or Grief Support Network Yoga Therapy Program in the past?
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17. If so, please list the start date of the program and anything else you'd like to share about your experience.
Your answer
18. Emergency Contact
Your answer
19. Emergency Contact Email Address
Your answer
20. Emergency Contact Phone Number
Your answer
Background Information
Your answer
21. Have you been clinically diagnosed with a Mental Illness?
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22. If Yes to living with a mental illness, please explain and whether you are or are not in the care of a Licensed Mental Health Councilor or Therapist.
Your answer
23. What kind of loss have you experienced? (Check all that apply.)
23. When did your losses occur
Your answer
24. How is your loss affecting you now?
Your answer
25. Have you had more than one loss in the last 5 years?
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26. Are you currently in Counseling or receiving care from a Mental Health Therapist?
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27. What is your current support system?
Your answer
28. Have you experienced any events that you would consider traumatic, whether related to this loss or not?
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29. If so, please explain.
Your answer
30. Have you ever attempted or considered suicide?
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31. If so, was there any follow up treatment? If so, what?
Your answer
32. Are you currently taking any medications for depression, anxiety or other mental health issues?
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33. Have you ever been hospitalized for psychiatric reasons?
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34. If so, please explain.
Your answer
35. Do you experience fighting in your household?
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36. If so, please explain.
Your answer
37. Do you currently practice Yoga?
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38. If yes, please briefly describe the nature of your yoga practice.
Your answer
39. What other activities do you do to support yourself on regular basis?
Your answer
40. Please describe any injuries, acute or chronic, or disabilities that your Facilitator should be aware of that may/will effect your practice.
Your answer
41. Are you currently pregnant?
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42. Please tell me why you are interested in participating in the Awakening Through Grief 6 Week Yoga Therapy Program?
Your answer
43. Is there anything else you would like for me to know?