HOLISTIC HEALTH THERAPIES
333 Miller Ave Suite #7
Mill Valley, CA 94941
INTAKE FORM - Yoga Therapy Session
Please complete this form in advance in preparing for your first meeting.
Phone: Home ________________________Mobile _________________________
Health Care Provider____________________________________
Your Age ____ Gender____
Marital Status: ____________Number/Ages of Children: ___________________
What would you like your Yoga Therapy to accomplish or what issues do you want to work on through yoga?
Profession (past and present)
Hobbies and Activities, Favorite Subjects in School
Present Physical Activity, Exercise and Yoga Practice
Meditation / Spiritual Activity or Spiritual Affiliation
Living and Work Situations (peaceful, supportive, or challenging?)
1) Physical Environments (any issues with privacy, isolation, noise, etc?)
2) Emotional and Other Stresses (finances, primary relationships, colleagues, commuting, parenting or care-giving, etc.)
Are there any diseases or illnesses that run in your immediate family?
What are your main physical and/or emotional health concerns?