Intake Form | Breakthrough WellBEing

First Name*

Last name*

Email*

Gender*

Age*

Occupation*

Client symptom physical discomfort scale: Rate 0-10: Ten feeling excruciating pain. *

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Please Explain Physical Pain:

Client symptom mental discomfort scale: Rate 0-10: Ten feeling excruciating pain. *

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Please Explain Mental Pain:

Client symptom emotional discomfort scale: Rate 0-10: Ten feeling excruciating pain. *

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Please Explain Emotional Pain:

What outcome do you want from this time together (e.g., feel relaxed, peace, insight, etc.)?*

Please list to 3 things that you want to improve/bother you the most in your life (could be career related, habit, goal, physical, mental, relational, social, emotional, etc.):*

Do you have a situation/circumstance you want to address during the session (e.g., work challenge, upcoming decision, PTSD, sleep disturbances, etc.)? Yes/No; Explain*

Do you have a physical symptom you want to address during the session (e.g., posture, digestion, general malaise, etc.)? Yes/No; Explain*

General & Medical Information: Do you have any of the following conditions? If checked, please explain below as clearly as possible.*

Stress

Back Pain

Insomnia

Bruise Easily

Depression

Allergies

Cancer

Very Sensitive to Touch / Pressure

Joint Swelling

Contagious Disease

Wear Contact Lenses

Cardiac / Circulatory Problems

Frequent Headaches

Diabetes

Trauma / PTSD

Anxiety

Varicose Veins

Arthritis

Bipolar Disorder

Epilepsy / Seizures

Digestion Issues

Depression

Osteoporosis

Sleep Issues

Exhaustion

Brain Fog

High Blood Pressure - If Yes, Taking Medication For It?

Accident / Suffered Injuries in the Past 2 Years? Broken Bones, etc.

Numbness / Stabbing Pains (Specify Below)

Tension / Soreness in a Specific Area (Specify Below)

Other Medical Conditions Not Listed (Specify Below)

Additional Information:

List any medication are you currently taking:

Have you been hospitalized in the past 3 years? If yes, what was the reason?*

Are you under the care of a psychotherapist? If yes, please provide their name and phone number:*

Please provide an emergency contact / phone:*

Yoga therapy is the application of the principles and practices of yoga to promote health and well-being. Its aim is to eliminate, reduce, and/or manage symptoms that cause suffering; improving function; helping to prevent the occurrence or re-occurrence of underlying causes of illness; and moving toward improved health and well-being. ***I AM Yoga Therapy may include the use of appropriate touch to improve range of motion, alignment, and body awareness. Please choose one of the following below: *

I give Consent for my yoga consultant to use hands-on contact to assist my yoga therapy session. I agree to communicate with my yoga consultant about any particular techniques involving touch that I would prefer to drop or discontinue. I understand that I can inform the yoga consultant of my change in preference in this or future sessions, and that this change in preference will be documented.

I prefer a touch-free yoga therapy session. If the yoga consultant absolutely feels they must engage touch for safety in the pose, I understand they will ask permission to assist first. I understand that I can inform the yoga consultant of any change in preference in this or future sessions, and that this change in preference will be documented.

I understand that the yoga consultation I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the consultant so that the technique may be adjusted to my level of comfort. I further understand that a yoga consultation should not be construed as a substitute for medical examination, diagnosis or treatment. I understand that yoga consultants are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because yoga consultations should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the yoga consultant updated as to any changes in my medical profile during the session and understand that there shall be no liability on the yoga consultant’s part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the yoga consultant reserves the right to refuse a session to anyone whom he/she deems to have a condition for which the techniques of yoga are contraindicated. *

I agree

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