Yoga Therapy Consultation Form
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Email *
Name *
Date of birth *
MM
/
DD
/
YYYY
Address *
Contact number *
Email address: *
Referred by *
Yoga experience - Have you practiced yoga before? *
* If you answered yes in the previous question - How long did you practice? *
How often do you practice yoga? *
style(S) of yoga practiced most frequently: *
What is your current activity level? *
Describe activity and frequency *
What are your goals/ expectations for yoga practice? what benefits are you looking for? *
Required
Personal yoga interest *
Required
How do you rate your current level of activity? *
Lowest
Highest
Level of stress *
Lowest
Highest
energy level *
Lowest
Highest
Sleep quality *
Lowest
Highest
Work/life balance *
Lowest
Highest
How health do you consider your daily eating? *
Lowest
Highest
Physical history: please review this list and check those conditions that have affected your health either recently or in the past. *
Required
Describe and explain *
Describe treatment *
Have you had or currently have and pain or injury? (please note where in the body and details): *
Are you currently taking any medications? *
We are delighted to have you as a Yoga Therapy client. The following information will help you get the most out of your therapy session and clarify our instructor/client relationship. We believe that yoga is more than physical exercise. It is a transformative practice that integrates physical, intellectual, emotional, and spiritual elements to arrive at deeper levels of relaxation and awareness. Awareness is fundamental to the practice of Yoga. I understand that yoga involves some physical exertion and stretching, and I agree to take full responsibility for not exceeding my limits in the practice of yoga and for any injury or discomfort I might experience in the practice of yoga. I agree to inform my yoga therapist of any activities or movements, which I feel could cause injury to myself. I understand and accept that to properly teach and correct yoga technique, physical contact between student and instructor may be necessary. I consent to such contact and recognize that the instructor will apply any necessary contact in a professional manner. The yoga therapist shall not be held liable for any injury, loss or damage to property and/or persons sustained during or as a result of participation in this class. I agree to listen to my body and monitor myself during every yoga therapy session. (Please sign) *
Name *
Date of birth *
MM
/
DD
/
YYYY
Address *
Contact number *
Email address: *
Referred by *
Yoga experience - Have you practiced yoga before? *
* If you answered yes in the previous question - How long did you practice? *
How often do you practice yoga? *
style(S) of yoga practiced most frequently: *
What is your current activity level? *
Describe activity and frequency *
What are your goals/ expectations for yoga practice? what benefits are you looking for? *
Required
Personal yoga interest *
Required
How do you rate your current level of activity? *
Lowest
Highest
Level of stress *
Lowest
Highest
energy level *
Lowest
Highest
Sleep quality *
Lowest
Highest
Work/life balance *
Lowest
Highest
How health do you consider your daily eating? *
Lowest
Highest
Physical history: please review this list and check those conditions that have affected your health either recently or in the past. *
Required
Describe and explain *
Describe treatment *
Have you had or currently have and pain or injury? (please note where in the body and details): *
Are you currently taking any medications? *
We are delighted to have you as a Yoga Therapy client. The following information will help you get the most out of your therapy session and clarify our instructor/client relationship. We believe that yoga is more than physical exercise. It is a transformative practice that integrates physical, intellectual, emotional, and spiritual elements to arrive at deeper levels of relaxation and awareness. Awareness is fundamental to the practice of Yoga. I understand that yoga involves some physical exertion and stretching, and I agree to take full responsibility for not exceeding my limits in the practice of yoga and for any injury or discomfort I might experience in the practice of yoga. I agree to inform my yoga therapist of any activities or movements, which I feel could cause injury to myself. I understand and accept that to properly teach and correct yoga technique, physical contact between student and instructor may be necessary. I consent to such contact and recognize that the instructor will apply any necessary contact in a professional manner. The yoga therapist shall not be held liable for any injury, loss or damage to property and/or persons sustained during or as a result of participation in this class. I agree to listen to my body and monitor myself during every yoga therapy session. (Please sign) *
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