Yoga Therapy Intake Form
Hi there! I would love to hear how you're doing and help facilitate your further health and wellbeing using the tools of yoga. Please fill in as much as you feel comfortable sharing with me so that I can get to know you a little better. Everything you share with me will be kept confidential. Be advised that the Yoga is a complementary or integrative practice to be used in conjunction with standard medical care.
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Email *
Name *
Today's Date
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Age
Occupation
What do you hope to achieve during our yoga therapy sessions?
Check any goals you might be interested in:
I would like to (check all that apply):
Personal Yoga and Meditation Interests (check all that apply):
Do you have any physical challenges or issues you would like help with? Please indicate how long you've had issue(s) and any attempted treatment/response below
Do you have any psychological, emotional, or spiritual challenges or issues you would like help with? Please indicate how long you've had issue(s) and any attempted treatment/response below
Are you diagnosed with any medical conditions currently?
Please check those conditions that have affected your health recently, and for those checked provide more detail below.
Provide more detail for any checked responses above if you feel comfortable.
Do you have tightness, pain, or limitation in mobility in any of the following areas?
Please check those that apply to you:
Provide more detail for any checked responses above if you like.
On a scale of 1-10 how would you rate your overall level of pain
Minimal
Excruciating
Clear selection
Are you currently taking any medications?
Clear selection
If yes, please list names and reason for medication, if you feel comfortable.
Any supplements?
How do you rate your current level of activity?
Sedentary
Very Active
Clear selection
List some of the activities you enjoy the most, or do the most of - whether they are physical exercise like walking, or manual labor like gardening.
Do you currently practice yoga? If so, how often and what type?
Do you currently practice meditation? If so, how often and what type?
On a scale of 1-10, how would you rate your level of mental distress?
Not at all
Extremely
Clear selection
At what times do you experience the most mental distress or a busy mind?
On a scale of 1-10, how would you rate your level of stress?
Not at all
Extremely
Clear selection
Where/how do you experience stress in your body?
What is the source of, or the triggers of stress in your daily life? Please explain briefly.
How much sleep do you get each night on average
Clear selection
Which describes you best? Check all that apply
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How would you describe your current diet or meal plan? (For example, I am on the Keto diet...or I prepare most of my own meals which are low carb/high protein...or, I eat out a lot, etc)
Do you have any of the following habits? (no judgement)
What brings you joy?
Is there anything else you want to share that you think might be relevant, or provide more detail for?
WAIVER:    These yoga therapy sessions are led by a certified YOGA THERAPIST, C-IAYT. Please inform your yoga therapist of all mental and physical health conditions you have (i.e., high blood pressure, pregnancy, surgery, etc.), as they may affect your practice and sessions in ways you do not expect. I acknowledge that my participation is entirely voluntary. I understand that this program and its’ yoga therapists do not diagnose diseases or any physical or mental disorders, nor do they prescribe medical treatment.  I also understand that the classes, sessions and program do not constitute medical advice or advice otherwise given by an accredited mental health therapist. I have read, understood, and agree to the content of this Professional Disclosure and Liability. I hereby release Ann MacMullan and Ann Grace Yoga from any and all liability related to these sessions.   *
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PLEASE TYPE NAME BELOW AS SIGNATURE: I have read the above waiver and agreement and have fully understood its contents. By signing below, I am fully agreeing to all of the above statements. *
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