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Yoga Therapy Intake and Release Form
New Client Intake and Release
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Email *
First and Last Name/Preferred name/pronoun *
Date of Birth *
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Email *
Mailing Address *
Phone number *
Preferred communication *
Emergency Contact Name and Phone Number *
I understand that Yoga Therapy includes physical movements (asana), pranayama (breathing exercises), focused attention (meditation) and chanting or toning, as well as an opportunity for gained awareness. I recognize that this may require some physical exertion, which may cause physical injury, and I am fully aware of the risks and hazards involved. If I experience any pain, discomfort or nervous system dysregulation, I will listen to my body, stop the movement and/or practices, and ask for support from Shauna. Yoga Therapy is not a substitute for medical attention, examination, diagnosis, or treatment. These forms of exercise are not recommended and are not safe under certain medical conditions. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in any sessions with Shauna. I represent and warrant that I am physically fit and I have no medical condition which would prevent my participation. I knowingly, voluntarily and expressly waive any claim I may have against Shauna Langford Piscitello and Wellbeing with Shauna for any injury or damages that I may sustain as a result of participating in the sessions as stated above.I have read the above release and waiver of liability and fully understand its content. I voluntarily agree to the terms and conditions stated above. *
If in agreement with the above statement, please digitally sign and date below.
What is your reason for seeking yoga therapy today? *
Are there any physical or emotional conditions that you are currently in the care of a physician for? *
If yes, then please list and for how long? *
Please list any other conditions you are experiencing and for how long? *
Any allergies that I should be aware of?  Specifically to candles, perfumes, essential oils or other
Please list any medications and/or supplements you are currently taking *
How would you describe your current activity level? *
What is your experience with yoga, thus far?
Clear selection
If prior yoga experience, what style or lineage?
Are you currently working with some body discomfort or pain?  If so, please rate it at its worst.
No pain
Severe
Clear selection
Please describe and list the location and activity that may aggravate the pain/discomfort
Have you been treated for any of the areas listed in the previous section by a rehabilitation professional (i.e., acupuncturist, chiropractor, massage therapist, physical therapist, etc.)? If so, please describe your experience with the intervention(s) (i.e., treatments utilized, effectiveness of treatment with discomfort level, functional changes, etc.).
Please describe your current sleep status. (ie hours/night, sleep quality, sleep issues, etc) *
Please describe any significant mental health challenges, difficult emotions, stresses, issues or relationships in your life that you are struggling with:
Dietary Information:  How would you describe your typical daily food intake/nutritional status?
Current daily intake:  Please estimate how many ounces of water you drink daily:
Caffeinated beverages, diet or energy drinks daily?
Alcohol or other substances?
Are you currently involved in any support groups, spiritual/religious affiliations, or other social outlets you feel are crucial to your well- being? Please feel free to share specifics regarding your current social outlets.
What are your goals for therapeutic yoga?
In the course of a typical week, how much time are you able to commit to the process of achieving these goals? Do you perceive any barriers in committing this time?
Please share anything else you think is important for Shauna to know for the yoga therapy process
Permission for medical information release: 
By filling out and signing this form, I hereby grant permission (from entity/person stated below) to release my confidential health information to Shauna Langford Piscitello, for the purposes of informing our sessions pertinent to my therapy goals. 

Below, please put your name, date of birth and today's date and the health practitioner's name/phone number you are permitting release from or N/A if not providing consent.
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General Information & Policies for Helping Things Run Smoothly: • Wear comfortable, non-restrictive clothing that you can move well in.• A restroom is available that may be used as a changing space.• Please silence your cell phone during our time.• Your time is scheduled just for you! Because of this I cannot go past your scheduled time if you are late for a session.Privacy Policy• Your privacy is very important to us. Any personal information you choose to give us will only be used to help us provide you with the highest quality services, and support.• We will never share your personal information with any other party without your consent.                      

Cancellation Policy• I have a 12-hour cancellation policy for all sessions. If you miss a session or cancel within 12-hours of your scheduled time you will be charged for the session at the beginning of your next class.  I reserve the right to waive this fee under mitigating circumstances, i.e. sudden illness, etc.   An in person session can be converted to a Zoom session with at least a 30 minutes notification.  If the session is online, please be in a location that is private and undisturbed.  Camera view must be on and in full view for adequate instruction. Thank you for your understanding in this.                      
I have read the above policies and fully understand its content. I voluntarily agree to the terms and conditions stated above.  Sign (write name) and date below:
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