New Client Intake Form

Please feel free to skip any questions if you would prefer not to answer them. Your answers will be kept confidential.

Date

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email Address

Birthday

YYYY

Age:

Occupation

Name/Telephone of person to be notified in an emergency:

Why have you come to yoga therapy?

Are you currently taking any medication? If so, please list medications here.

Is there any time of day or night that you consistently experience pain or discomfort?

Please describe the quality and/or location of any pain or discomfort that you are experiencing.

What types of exercise or physical activities do you participate in, and with what frequency?

What do you do when you are in pain to feel better?

What makes the pain worse?

What health professionals have helped you the most?

I am a certified yoga therapist who is passionate about helping people reduce stress & anxiety, ease chronic pain, and find a path towards happiness and healing. I focus on gentle yoga, therapeutic yoga for injuries and illnesses, and Kundalini yoga. I offer private and online yoga sessions, lead local and international retreats, and host trainings and workshops that are designed to help empower you with the tools you need to heal, transform, and thrive. I specialize in working with cancer patients during and post treatment, and strive to make yoga accessible to all.