Client Intake Form

Client Intake, Policies and Waiver

Please fill out what is relevant and comfortable for you at this time. There may be sections that you do not need to complete any information. Parents, please answer questions on your child's behalf, soliciting their input where you deem appropriate.
Client's Full Name

First NameLast Name
Parent's Full Name (if client is a minor)

First NameLast Name
Preferred Pronouns
Date of Birth

MonthDayYear
Primary Phone
Format: (000) 000-0000.
Email Address
Please select your preferred method(s) of contact:
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

NameRelationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you learn of my services?
What kinds of challenges are you experiencing right now?
What are your reasons for coming to yoga therapy? Do you have any particular goals?

Please tell me a little about your lifestyle, such as dietary intake, exercise habits, smoking or drinking habits.
Describe a typical day for you.
Do you consume nutritional supplements, prescription medications or other health-related products? If yes, please list those and any side effects that you experience.
Do you awaken from sleep feeling rested?
Do you fall asleep easily?
Using a scale of 1-10, with 1 indicating the lowest level, how would you rate your general stress level?
What types of situations trigger stress in your everyday life?
What are some of the ways you find most effective to relax or release stress?
How do you have fun in your life? How well do you feel nourished? How do you enjoy nourishing yourself, such as food, relationship, alone time, laughter, entertainment, nature...?
Are there current habits you would like to change? Are there new habits you would like to develop?
How would you describe your state of mind most of the time?
How would you describe your relationship with social technology, such as social media, email, and general screen use for work and/or recreation?

Health and Well-Being Checklist:

Rows	Below Satisfaction	Needs Improvement	Satisfactory	Very Satisfied
Balance & Stability
Physical Fitness & Mobility
Body Awareness
Nutrition
Water Intake
Digestion
Sleep Quality
Energy Level
Quality of Breath
Concentration/Focus
Memory
General Mood
Support Systems
Meaningful Relationships
Intuition
Ability to Handle Stress
Ability to Observe Your Thoughts & Patterns
Sense of Meaning & Purpose in Life

Age:
Name
Siblings:
Names and Ages
What are some of your child's strengths? What qualities do they appreciate about themself?
How many close friends does your child have? Would they like this to be different in any way?
What does your child like most about school? What do they like least about school?
Does your child participate in any after-school activities? Please list them.

Please indicate your child's behavioral tendencies, knowing that this does not fully define them or their potential.

Rows	None	Mild	Moderate	Extreme
Relationship problems with siblings
Problems with other children
Parent-Child difficulties
Anxiety/Worry
Moodiness/Irritability
Fatigue/Disinterest in activities
Very active
Tension
Easily upset
Frequent crying
Feeling unhappy
Destructive behavior
Lack of self-confidence
Loneliness
Anger
Confusion
Pervasive Fears/Phobias
Dishonesty
Ability to concentrate
Thoughts of harm (to self or others)
Enjoys novelty (trying new things)

How did you complete the behavioral questions above?
Is there anything else you, or your child, would like to mention?

Approximately how long have you been intending to conceive?
Have you explored a fertility medical evaluation for yourself and your partner? Have any potential factors been identified? Please share about your experience, to the level that feels comfortable for you.
Are you currently utilizing any approaches or interventions for fertility?
Are there any life factors that you feel could be affecting conception?
Do you have general or specific concerns about pregnancy, birth or postpartum?

Please identify any areas of physical pain, sensitivity, limited movement, tension, or stress. How long has this been going on? Do you have any thoughts about it?
Have you consulted with a healthcare practitioner? If so, did you receive any diagnosis? Please describe:
What makes your pain worse?
What provides some relief?
Are there other health or medical conditions, precautions, treatments or situations to mention, to help support your well-being?

Yoga therapists are not licensed healthcare providers, but our training helps us better communicate with them. Select "Yes" if you would like me to check in with your provider about what we're doing. (This could be a doctor, counselor, therapist, psychiatrist, chiropractor, physical therapist, massage therapist, etc.)
Provider's Name
Profession
Provider's Phone
Please enter a valid phone number.Format: (000) 000-0000.
What information would you like to be shared?
Are there additional providers you would like to include? Please list additional providers here (name, profession, phone number and context).

The next questions ask about prior yoga or meditation experience. Yoga is about your relationship with the world- it is not simply about movement.
- You do not need any prior experience.
- You do not have to be flexible.
- You do not need to have it all "together" to begin.
For more information, read about how Yoga therapy is different from exercise yoga.
What is your experience with yoga poses, meditation and/or aspects of yoga?
If you currently practice yoga, how often do you practice and is your practice regular?
What have you found most beneficial from these practices?
What have you found most difficult or challenging?
What do you hope to gain from a yoga practice? What is your main goal for practice?

Yoga is a wellness practice that invites the client into balanced living. Beginning with goals created by the client, client and yoga therapist work to create a deeper intention behind these goals using a variety of yoga techniques. Yoga techniques include, but are not limited to, physical movement, yoga postures, adapted breathing techniques, relaxation, meditation, philosophy and yoga psychology. As are appropriate for the client’s belief systems, lifestyle factors such as relationships, attitudes toward work, and personally meaningful spiritual aspects may be explored.

The client is an active participant in the yoga therapy process, with the yoga therapist serving as a companion who supports the client on their journey. Clients are responsible for setting and working toward their chosen goals between sessions.

Sessions are 60 minutes in length and will begin and end on time. It is recommended that the yoga therapist and client meet weekly for the first month to support consistency with goals and intentions.

Assessments or practices may be given between sessions. Clients are encouraged to complete these assignments, as they support progress outside the yoga space and help the yoga therapist tailor sessions effectively.

Therapeutic Boundaries

Yoga therapy is not a licensed healthcare profession and is not used to diagnose or treat a specific illness or injury. All sessions are confidential and will not be discussed outside the session unless the client expresses an intent to harm themselves or others. Conversations during sessions will remain focused on the client, as this is a professional relationship.

The yoga therapist reserves the right to discontinue sessions if the nature of the relationship no longer feels therapeutic. If the yoga therapist suspects—or the client discloses—being under the influence of alcohol or other mind/mood-altering substances during a session, the session will be ended promptly.

Please provide at least 24 hours’ notice if you need to cancel or reschedule your yoga therapy session. Cancellations made with less than 24 hours’ notice will result in the full session fee being charged or one session deducted from your package.

To reschedule a session, please contact your yoga therapist directly to request an alternative date and time.

If you have a scheduled session and do not show up—or do not contact your yoga therapist within 15 minutes of the session’s start time—it will be considered a no-show. In this case, the session will need to be rescheduled. To avoid being charged for the session or having it deducted from your package, please provide at least 24 hours’ notice for cancellations or rescheduling.

Maintaining a consistent session schedule is important. If three (3) sessions in a row are canceled with more than 24 hours’ notice, one session will be deducted from your package or the full session fee will apply. This helps honor the yoga therapist’s time and supports access for other clients who may be waiting to book.

A. I agree that Spacious Mothers LLC is in no way responsible for the safekeeping of my personal belongings while I attend class/session. I understand that classes/sessions may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury, property loss or death. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice yoga. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against Spacious Mothers LLC, its staff, private contractors or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise.
B. If Participating while Pregnant or with an Infant/Child: I individually and as parent and/or guardian of the minor child hereby acknowledge the following notices and grant Spacious Mothers LLC the following release from liability: I acknowledge and fully understand that I, or my child, will be engaging in physical activities that may involve some risk of injury. I acknowledge and have been advised that it is my responsibility to consult with my or my child’s physician with respect to any past or present injury, illness, health problem or any other condition or medication that may affect my or my child’s participation. I assume the foregoing risks and accept full personal responsibility for any personal injuries sustained by my child or myself which might incur as a result of participating in this program and discharge and hold harmless Spacious Mothers LLC, its owners, directors, members, employees and agents from any claim, cause of action or liability for damages arising from any personal harm to myself, my child or other persons or property caused by myself or my child’s participation in yoga classes.
C. I understand and agree that if this waiver is signed electronically, a photocopy or electronically signed version is an acceptable substitute for the original and holds the same force and effect as a wet ink signature.
By signing below, you confirm that you have read, understand, and agree to comply with the above Yoga Therapy Process & Guidelines, Session Cancellation & Rescheduling Policy, and Liabilty Waiver.
Signature

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Client Intake, Policies and Waiver