Intake Form

First Name

Last Name

Phone

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

List your current & previous health conditions? Please include medical diagnoses, surgeries, accidents, injuries, etc., and approximate dates. How long has your current health issue been going on? Who else are you currently seeing for your health concerns or general health promotion? How often do you see them? Please list your current medications, including supplements.

Where do you hold tension in your body? What relieves your pain? What increases your pain? Think about ranges of motion, movements etc. Indicate the pain descriptions that apply most to you.

What are your favorite physical movements? Least favorite? Do you have a regular exercise program? Please describe? What are your current reasons for seeing a yoga therapist? Do you have a goal for our time together?

What life challenges are your currently facing? What aspects of your life gives you the most joy and pleasure? If you could change one thing, what would it be?

How much time (each day/week/month) can you devote to your own personal yoga practice?

Thanks for submitting!