Intake Form

Name*

Phone

Nickname

Email*

Occupation

Date of Birth

Address

City, State, Zip

Referred By

Name

Relationship to you

Phone

Describe your primary reason for seeking Yoga Therapy. What are your goals for our time together?

On a scale of 1-10, (1 is lowest, 10 is highest) how would you rate your:

Energy level

Level of stress

Eating habits

Level of activity

Quality of sleep

Digestive process

What life challenges are you currently facing?

What aspects of your life give you the most joy and pleasure?

Are you currently taking any medications?* YesNo

If Yes, please list names and reasons for medications.

Are you pregnant?* YesNo

If Yes, EDD?

I HEREBY AGREE TO THE FOLLOWING:*

It is my choice to receive yoga therapy. I understand that yoga therapy is provided for the well being of my body and mind, and in no way takes the place of a doctor’s care when it is indicated. I acknowledge that yoga therapy is not a substitute for a medical examination or diagnosis, and that it is recommended that I see my primary health care provider for that service.
I agree to inform my yoga therapist of any physical limitations, discomfort and/or injuries before or during yoga therapy, as well as activities or movements, which I feel could cause injury to myself, and I take full responsibility for any nondisclosure.
I understand that yoga therapy involves some physical exertion and stretching, and I agree to take full responsibility for not exceeding my limits during the practice as well as for any discomfort and/or injury I might experience during the practice.
I understand and accept that to properly teach and correct yoga technique, physical contact between me as a client and yoga therapist may be necessary. I consent to such contact and recognize that the yoga therapist will apply any necessary contact in a professional manner.
Yoga therapist shall not be held liable for any injury, loss or damage to property and/or persons sustained during or as a result of participation in yoga therapy.
I agree to listen to my body and monitor myself during every yoga therapy session.

Client’s Signature:*

Date:*