Yoga Therapy Intake Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Age/DOB

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Referred by

What are your current reasons for seeing a yoga therapist? Do you have a goal?

What yoga therapy facets are you most interested in?

Structural Rehabilitation, Yoga Asana (postures)Somatic Movement and Embodiment PracticesPranayama Breathing TechniquesMeditationGuided Imagery/RelaxationSubtle Body/Tantra (Chanting/Mudras/Chakras)Preparation to attend weekly classes

Do you have prior experience with any of the above mentioned aspects of yoga? If so, what did you like / dislike?

Please list any challenges, illnesses or injuries that you want to address or that may affect your yoga therapy practice. Explain in detail with approximate date of onset.

Have you experienced any significant physical or emotional traumas?

Who else are you currently seeing for health concerns or lifestyle wellness? How often do you see them? Would you like me to share your information? If so, please include their contact information.

Please list your current medications, including supplements.

Briefly describe your typical diet. How is your digestion and elimination? do you have daily bowel movements? Would you describe them as normal, loose or constipated?

How would you describe your current level of stress on scale of 1-10 (1 low, 10 high)?

Please describe each area as improving, deteriorating or staying the same and any additional comments.

Home Life

Work Life / Volunteer

Physical Health

Mental / Emotional Health

Spiritual beliefs / practices / affiliations (Is your belief a source of support to you?)

What are your current self care practices, hobbies and interests that are most valuable to you?

Are there areas of discomfort in your body?

YesNo

If yes, please describe location, type / degree of pain and what increases and relieves your pain.

Where do you hold tension in your body?

Is your sleep satisfying?

YesNo

If no, please describe your sleep patterns, medications and total hours of sleep.

How much time can you put aside daily or weekly for yoga therapy?

Embody with MM | +353 87 409 7765 | embodywithmm.com

Yoga Therapy Intake Form

Basic Information

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