Yoga Therapy Intake Form

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Welcome to your journey with Yoga Therapy!

We truly honor your commitment and desire to want to put in the work, look deep inside, and remember who you are in an effort to heal and grow.

Email *

Name

Phone Number

What times are you available?

Please select all that apply

Morning

Midday

Afternoon

Evening

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Any additional explanation of the availability

List any injuries

If comfortable sharing, please list any traumatic events that you may have experienced. The body tends to hold on to emotions and could be affected after any traumatic life experiences, every person is unique and the more information you provide the more we can customize your specific treatment plan.

List any other pain/ or changes in the physical or energetic body since the injury or events occurred.

Main goal for Yoga Therapy or What brings you to Yoga? What are your areas of concern? (Including any Physical Pain, Mental Stress etc.)

List any medications

Do you smoke tobacco?

Yes

Clear selection

Do you drink alcohol?

Yes

Rarely

Clear selection

Do you use caffeine?

Yes

Rarely

Clear selection

How well-rested do you feel after sleep?

Still Tired

Completely rested

Clear selection

Do you feel anxiety or stress? And if so please describe when you feel this way or what you are doing when you feel this way?

Yes

Sometimes

Clear selection

Any other comments and/or questions?

Have you ever practiced yoga or meditation before? *

Yes

Maybe

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