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Intake Form for Barbara Ley Yoga
Hello! Thank you for participating in my Yoga Therapy Practicum, which is the final module of my clinical yoga therapy program. Please fill out this form as soon as you reasonably can so that we can get your scheduled! The intake form also helps me get to know you and your yoga therapy needs better. When it comes to the personal information/reflection questions, feel free to provide as little or as much information as you're comfortable with. Please let me know if you have any questions, and I look forward to working with you! 
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Email *
I. Basic Information 
Your Name
What are your gender pronouns? 
What is your age? *
Address *
Phone number
What is your occupation? 
What are your accessibility needs, if any?
II. Getting to Know You and Your Yoga Therapy Needs
What is your predominant reason for seeking yoga therapy? *
List any other notable current and/or previous health conditions (e.g., symptoms, medical diagnoses, surgeries, etc.) that you've experienced. Provide approximate dates, if possible.
What other services (e.g., mental health therapy, MD, physical therapy, acupuncture) are you receiving for your current health concerns/conditions and for your overall wellbeing?
Tell me a little about your lifestyle as it pertains to your diet/eating habits, daily water consumption, exercise habits, sleep patterns, alcohol use, etc. 
Tell me a little about your everyday life responsibilities as they pertain to your occupation, your household, your family, your community, etc. 
What are some of your hobbies, interests, and activities that bring you satisfaction and joy? What activities would you like to do more of to increase joy in your life? 
Briefly describe your current and/or previous experiences with yoga, mindfulness, ayurveda, and other related practices. What are your thoughts about these practices and their impacts (if any) on your overall wellbeing?  *
What are your goals for your yoga therapy sessions with me? What guideposts or markers would help you assess your progress along the way? 
Is there anything else you'd like me to know about? Do you have any additional questions for me?
A copy of your responses will be emailed to the address you provided.
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