Yoga Therapy Intake Form

Yoga Therapy Intake Form
Basic Information
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Age/DOB

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Referred by
Questionaire
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 Practices Pranayama Breathing Techniques Meditation Guided Imagery/Relaxation Subtle 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?

Yes No
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?

Yes No
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?
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Yoga Therapy Intake Form

Basic Information

Questionaire