Yoga for Healing Interest/Intake
Thank you for your interest in Yoga for Healing. Please note that this class is free and open to only 12 participants (UW Students ONLY). In the case this class fills up, you will be put on a waiting list and we will email you with information pertaining to future classes.  
 
Registration:
Our registration page requests some personal information so that we can provide the best experience possible for all students. Some of the questions inquire about sensitive topics. Therefore, if you would like support filling out this form, please contact one of our on campus Advocates (Brittany bmbow@uw.edu or Tori vadams@uw.edu). In addition, if anything comes up in your registration that we are concerned about, one of our Advocates and/or yoga instructor might reach out to you for more information or to offer support.
 
Please be aware that protecting your private information is a high priority. Therefore, the information contained in this form will only be accessed by the few university officials connected to this program including the Health & Wellness Advocate, Mindfulness Manager, and yoga instructor.
 
Logistics:
Class for Spring quarter will take place Fridays 1:30-2:45pm (05/03 - 06/07) at the IMA (Studio 316). While it is recommended to have a yoga mat, if you do not own one there will be extra mats for your use.
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Full Name (First, Last) *
Email *
Student ID # *
Gender
Preferred Pronouns
Your Phone Number *
Emergency Contact Name *
Emergency Contact Phone Number *
How often have you experienced each of the following in the last month (0=never to 3=often). This information will be utilized by your instructor to better support you in your class experience.
0
1
2
3
"Flashbacks" (sudden, vivid, distracting memories)
Anxiety attacks
"Spacing out" (going away in your mind)
Sadness
PTSD
Desire to physically hurt yourself
Dissociation
Feeling tense all the time
Having trouble breathing
Desire to physically harm others
Unsupportive coping strategies (drugs & alcohol, medication, WHAT ELSE?)
Is there anything else that you have experienced that you think we should know about regarding your physical and/or mental wellbeing?
Please list any medications that you’re on that could interfere with yoga (e.g., could cause dizziness, fainting, etc.).
What on or off campus resources have you used to assist you in your healing process (personal counseling/talk therapy, medical attention, alternative therapies, legal assistance, etc.) if any.
Do you have a trusted support system (family, friends, counselor, etc.)?
Clear selection
Are you interested in receiving more information about mental health support resources at this time?
Clear selection
Have you practiced yoga before? *
If yes, what kind of yoga and for how long? (If no write in n/a) *
How did you hear about this program? *
Why do you want to participate in a class focused on Healing? *
It is required to either meet with or have a short phone conversation (15-20min) with our instructor before the class begins to discuss any questions and/or concerns that you might have, and to get to know you a little better? Our instructor will be in touch to schedule a time. If you have any questions about this please feel free to ask.  
If I am registered for this class, I agree to communicate ASAP if my schedule no longer allows me to attend (so we can allow others on the waitlist to take the class). Fill in NAME and DATE. *
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