Yoga Therapy Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Age Group
*
Please Select
13-20
20-30
30-40
50-60
70-80
80–Above
Gender
Male
Female
Non-Binary
Prefer not to say
Health History
*
Stress
Physical injuries
Chronic issues
Sleep issues
Pregnancy
Mood disorder
Burnout
Anxiety
Focus issues
PTSD/Trauma related
Loneliness
Surgery
Diabetes
High blood pressure
Postpartum
Non Productivity
Thyroid
Other
None
Caffeine/ Nicotine / Substance/ Alcohol use
*
Please Select
Multiple times a day
Once a day
Weekly
Few times a month
Rarely
Never
Are you taking any medication that affects your awareness, sleep and or Nervous system?
*
Yes
No
How often do you move your body?
*
Please Select
Daily
Few times a week
Few times a month
Rarely
Never
Do you have any issues or discomfort while laying down or reclined seating?
*
Please Select
Yes
No
Emergency Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you consent to
*
Being recorded for personal review / teaching purposes
I do not wish to be recorded
Consent & Liability Waiver
*
By signing below, I understand that all yoga therapy services offered by The Holistic Flower Child LLC are for support, education, and personal well-being. These sessions do not replace medical care, mental health treatment, or emergency services. I acknowledge that I am responsible for my own health, choices, and safety during and after each session. I agree to communicate any concerns, injuries, or changes in my physical or emotional state.
Signature
*
***Tips are highly appreciated ***
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