Welcome to your Yoga Therapy Intake Form

Al of the information you provide assists me in customising your Yoga Therapy consultations to suit your individual needs. 
All information is treated with the utmost confidentiality and only supplied to medical practitioners on request. 

Cancelation Policy
I agree to give 24 hours notice for any cancellations or modifications to my scheduled appointment or I will be charged in full. I understand that time will not be added to my appointment for tardy arrival and I will be charged in full for my scheduled session.

Would you like to learn more about the following:

Do you have any current mental or physical health concerns you would like to focus on?

Have you practiced yoga before?
If yes, how often do you practice yoga?
What style/s of yoga have or do you practice?

Do you exercise?
If yes, how often do you exercise per week?
Describe your current exercise practice:
Do you smoke?
Do you drink alcohol?
If yes, please note down how many standard drinks per day/week/month.


Please describe your eating patterns.
For example, do you have a tendency to feel hungrier earlier in the day or later? Do you tend to eat an early dinner or late?
Do you regularly skip meals?

On a scale from 1 (low) to 5 (high), what is your current level of stress?

Do you have difficulty sleeping?
What is the average amount of hours per night you sleep?

Please review this list and check those conditions that have affected your health either recently or in the past:
Auto Immune Condition(s) Type

Cancer, Type:

Are you pregnant?

Please briefly describe where you currently feel:

Physical Pain

Are you currently taking any medication?

Please list here:
Please list any surgery(s) you have had, including dates.
Please list any other modalities you are currently using and why. (i.e. Physiotherapy, Chiropractic, Acupuncture, Deep tissue Massage etc.)

Preferred Treatment Plan
Therapy Options

Time Commitment:

Thank you for all the time it has taken to complete this form. If there is anything else you wish to add, please write it below.

It is essential in your yoga practice that you take responsibility for your physical well-being. Please read and sign the following release:

• I understand that Yoga Therapy is not a substitute for medical advice: Yoga and Yoga Therapy is not a substitute for medical examination, diagnosis and/or treatment.
• I understand that it is my responsibility to consult with a physician prior to and regarding my participation in Yoga Therapy. I accept responsibility for informing the Yoga Therapist about any medical conditions, injuries, pregnancy or changes to my health that may affect my practice, prior to a class commencing.
• I understand that it is my responsibility to practise within my personal limits and to decide whether or not to follow the advice and guidance provided by the Yoga Therapist.