Yoga Therapy Intake Form | holistic-health

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.

Name_______________________________________________________________

E-mail _____________________________________________________________

Address ____________________________________________________________

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?

Holistic Health Therapies