Email

Your Age

Referred By

(If you were not referred by someone, how did you hear about Temple Road Journey?)

Current Occupation

Emergency Contact Name

Primary Care Physician Name

(Write none if no PCP)

Please list any services you are currently receiving

(Mental health therapy, physical therapy, MD, ND, acupuncture, etc)

What is the main reason you are coming to yoga therapy?

What goals do you hope to achieve in our work together?

Please describe any observations you have made regarding your mental/emotional state in relation to your current challenge(s)

These may include thoughts that you have have or changes in your thoughts or emotions

Please list any current and/or previous health conditions including surgeries, diagnoses, accidents, injuries, etc, and approximate date

(Instances from just this year are fine)

Please note areas of pain or discomfort in your body

This will let me know both where you are experiencing pain, and also what postures or methods we should avoid to not further aggravate your pain

What makes your pain better?

Think about ranges of motion, movements, positions, etc

What makes your pain worse?

(Think about ranges of motion, movements, positions, etc)

Briefly describe your typical diet

What types of foods are you typically eating? Do you avoid any types of food?

Please complete this sentence: When I think about my current challenge(s) I feel:

Have you recently experienced suicidal thoughts or attempted suicide?

If yes, please provide some details

Have you ever experienced hospitalization related to mental health issues?

(If yes, please elaborate with dates, reason(s) for hospitalizations, name of facility, and length of stay)

What are your central religious/spiritual beliefs and practices, both current and past (if any), and how have these been affected in relation to the current challenge(s)?

What are your favorite physical activities or hobbies?

Is there anything else you would like me to know about you that I did not ask?

New Client Yoga Therapy Intake Form

Thank you for submitting your intake form. I look forward to our work together.

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